FORM A
UNIVERSITY OF KENTUCKY
COLLEGE OF HEALTH SCIENCES
CLINICAL LEADERSHIP & MANAGEMENT PROFESSIONAL APPLICATION
1.Name: ___________________________________________________________________________________
Last
First
Middle
(Maiden)
2.Date to Birth: _____/____/_____ Age: __________ 3. Social Security Number:___________________________
4.Ethnic Background (check one): Optional – this us used for statistical summaries ONLY and has no bearing on your application status.
___
Hispanic
___
White/Non-Hispanic
___
Puerto Rican
___
African American
___
American Indian
___
Other (Specify)_________________
___
Mexican American
___
Asian/Pacific Island
5.Applying for:
CLINICAL LEADERSHIP AND MANAGEMENT PROGRAM
I am applying to _____ Lexington campus
____
____
4-WK
FALL
____
____
8-WK
SPRING
_____ Hazard Campus
6.INDICATE WITH A CHECK MARK THE ADDRESS FOR CORRESPONDENCE
[ ]
Permanent Address:__________________________________________________________________
Number/Street
__________________________________________________________________________________________
City
County
State
Zip
__________________________________________________________________________________________
Telephone Number
Cell Number
Email address
[ ]
Present Address:_____________________________________________________________________
Number/Street
____________________________________________________________________________________________
City
County
State
Zip
___________________________________________________________________________________________
Telephone Number
Cell Number
Email address
7.Name of Parent or Guardian:__________________________________________________________________________
Address:___________________________________________________________________________________
Street
City
State
Zip
Phone
8.Have you previously applied for a CHS professional program? (___) Yes
(___) No If yes, give date(s):________________
9.List all undergraduate colleges, universities, or professional schools, beginning with the institution currently or most
recently attended. (Please use additional paper, if needed).
Degrees OR
Institution & Address
Declared Major
Month/Year
to
Month/Year
Certificates
Earned
10.Residency (you must complete all four questions):
a.Have your lived or worked full time in Kentucky for the last 12 months?
b.Have you received financial support from an individual out-of-state during the last 12 months?
c.Are you a resident of Kentucky?
d.Does either parent (or legal guardian) live in Kentucky?
(___)Yes
(___)Yes
(___)Yes
(___)Yes
(___) No
(___) No
(___) No
(___) No
11.Please submit ONE Letter of Application indicating your reasons and qualifications for desiring to enter the health profession of
your choice. You may include discussion of related employment or volunteer experiences, academic honors, etc.
I understand that (1) it is my responsibility to insure that all application materials are received by the deadline date and (2)
that withholding or giving false/misleading information will make me ineligible for admission and enrollment.
_______________________________________________
Applicant’s Signature
1
____________________________________
Date
INSTRUCTION SHEET FOR APPLYING TO THE
COLLEGE OF HEALTH SCIENCES
This is a SELF-ASSEMBLED APPLICATION PACKET which requires that the applicant obtain and complete all application
material, place it in a single envelope and send OR deliver to the following address:
Office of Student Affairs & Admissions
College of Health Sciences
900 South Limestone (CTW Bldg.), room 111
Lexington, KY 40536-0200
Non-University of Kentucky students must also complete a University of Kentucky application and send OR deliver to the
following address. You may obtain UK Application from the address below or download from their UK web site:
Office of Undergraduate Admissions
University of Kentucky
100 W. D. Funkhouser Building
Lexington, KY 40506-0054
www.uky.edu/UGAdmission/
COLLEGE OF HEALTH SCIENCES PROFESSIONAL APPLICATION
Admission deadlines:
Admission Term
Application Available
Deadline Date (Post Marked)
Fall
Spring
November 1
March 1
February 1
June 1
Applications may be hand delivered to the Office of Student Affairs & Admissions, UK Wethington Building, room 111, 900 South
Limestone, Lexington, KY. Applications must be received by the deadline date and submitted in ONE packet. An
“incomplete” application will NOT be reviewed.
The application packet should include:

The College of Health Sciences Professional Application (FORM A). This form should be completed with all required
information.

References: Three (3) reference forms (FORM B) must be provided to your references and then returned to you in a sealed
envelope with their signature written across the seal. (It is your responsibility that they understand these instructions and we
suggest that you provide them with a self-addressed stamped envelope with the form). These references should be placed in
your professional application packet.

Courses in Progress Form (FORM C): This form should be completed with all required information.

Letter of Application: All applicants are required to write a formal “Letter of Application” stating your reasons and
qualifications for desiring to enter the Clinical Leadership and Management Program and your plans after graduation
from the College of Health Sciences.

University Studies Program Worksheet (FORM D): This form must be filed out as completely as possible. This form
will be evaluated in terms of your University Studies requirements.

Professional Experience Worksheet (FORM E): Applicant must complete this form with all required information.

Verification of Associate Degree.
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TRANSCRIPTS
There are two (2) categories of applicants – please identify your category and follow those instructions. For our purposes any type of
transcript is acceptable to allow us to begin the evaluation process.

1.UK Enrolled Students: Need to supply the College of Health Sciences with transcripts: Official, unofficial, or even copies
indicating all college work attempted. Except, work completed for the Associate Degree must be submitted on a transcript
from that particular school. These transcripts should be placed in the CHS application packet. Transcripts may be obtained
two ways: 1) you may obtain transcripts from the Registrar’s Office, 10 Funkhouser Bldg. Cost is appx. $5.--, two day turn
around OR appx. $8.00 same day mailed or picked-up. 2) You may access a copy of your UK courses and grades via the
internet (www.uky.edu/registrar).

2.All Other Students Enrolled at Other Colleges including Community Colleges: Must place transcripts in your
Health Sciences application packet. Your transcript from your Associate degree granting institution must be official and
indicate, at the bottom, your general education requirements certification status.
Health Sciences will accept any kind of transcript to allow us to begin the evaluation process. All non-UK students will have
to supply official transcripts to UK Admissions Office.
UNIVERSITY OF KENTUCKY APPLICATION
(All Non-UK Students)
Two (2) categories of applicants (please follow instructions accordingly):
1.
Community College Students All applicants who are currently enrolled at a Community College must complete a UK
Application and request official transcripts from all colleges or universities attended. Official transcripts should be sent to the
Office of Undergraduate Admissions. The $40.00 application fee is not required of students previously enrolled at Community
Colleges. (Subject to change)
2.
All Non-UK Students All applicants who are not currently enrolled at the University of Kentucky must complete a UK
Application and include the $40.00 application fee with the application. The check must be made payable to University of
Kentucky. You must request official transcripts from each and every college/university which you have attended. Official
transcripts should be sent to the Office of Undergraduate Admissions in order for your application to be complete.
NOTE: The Office of Undergraduate Admissions will work with you to be admitted to the University. Any questions regarding your
admission to UK must be directed to the Office of Admissions. On your UK application, be sure to identify your
intention to apply to a professional program in the College of Health Sciences. If you are not accepted for this
program but you elect to transfer to UK anyway, you must contact the University’s Undergraduate Admissions Office and alert
them that you will seek pre-professional status.
Additional copies of application materials are NOT available, therefore, please make copies of those additional forms you need.
Application materials are NOT returned to the applicant.
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ASSEMBLY INSTRUCTIONS
ASSEMBLY INSTRUCTIONS AND CHECK LIST
Since the application process is complex, we have provided this checklist to assure that all steps have been completed.
Please initial each item (if applicable) as it is completed and send this form with your application.
UNIVERSITY OF KENTUCKY APPLICATION:
Send the following to the University of Kentucky, Office of Undergraduate
Admissions (for all students NOT currently enrolled at UK, Lexington campus).
_____ University of Kentucky Undergraduate Application.
_____ $40.00 Application Fee for all students unless you are currently enrolled at a Community College.
_____ Official Transcript from each and every college/university attended.
_____ Official Transcript from your High School, if you are using 2 years of Foreign Language to satisfy your USP requirements.
COLLEGE OF HEALTH SCIENCES APPLICATION:
All material must be included in ONE packet and sent to, or
hand delivered, to:
Office of Student Affairs & Admissions
UK Wethington Building, rm 111
900 South Limestone Street
Lexington, KY 40536-0200
_____ Professional Application. (Form A)
_____ Letter of Application.
_____ References Forms (3), sealed and signed. (Form B)
_____ Courses in Progress Form. (Form C)
_____ University Studies Program Worksheet. (Form D)
_____ Transcripts: Transcript from Associate Degree granting school must be an “official”. Transcripts from other
colleges/universities may be either official or unofficial.
_____ Professional Experience Worksheet. (Form E)
_____ Verification of Associate Degree. (As indicated on official transcript)
If you include a self-addressed stamped postcard, it will be returned to you with the date your application was received.
Self-addressed stamped Notification Postcard included: _____ YES
Signature
_____ NO
Date
We apologize that we cannot discuss your application packet over the phone nor can we discuss your application status.
Thank you.
C:Admissions/CLM/FormA Application
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