Application Form
Armstrong State University
Bachelor of Health Sciences Degree Program
11935 Abercorn Street, University Hall 154
Savannah, GA 31419-1997
Phone: 912.344.2548 Fax: 912.344.3490
Dr. Bob LeFavi, Department Head
(Print or Type)
1. Name: ____________________________________ Date: ________________
2. ASU ID#:_907_________________________ Date of Birth: ____/____/______
3. Semester / Year of Initial Enrollment in the BHS Program:___________/_______
4. Permanent Address:_________________________________________________
Street
__________________________________________________________________
City
State
Zip
5. Local Address:_____________________________________________________
Street
__________________________________________________________________
City
State
Zip
6. Phone Numbers: Home:( ) ________________Work:( )_______________
Cell Phone: ( )________________________
7. Email address:______________________________________________________
8. Person to be notified in case of emergency: Name: ________________________
( )_________________ __________________________________________
Telephone
Street
__________________________________________________________________
City
State
Zip
9. Gender: Female ( ) Male ( )
10. Ethnicity: (Check One)**
Caucasian, Non-Hispanic
Native American/Alaskan Native
Asian
African American, Non-Hispanic
Multiracial
Native Hawaiian or
Pacific Islander
Hispanic or Latino:
Mexican
Puerto Rican
Other Hispanic
** This information is confidential. It is used for statistical analysis only.
I certify that the information submitted in this application is complete and correct to the
best of my knowledge and belief.
Signature: _________________________________________________________
Some Bachelor of Health Sciences students will be required to complete a practicum
during their senior year. If you are required to complete a practicum/internship for
the BHS degree, you should be aware of the following requirements listed below. If
you have any questions regarding these requirements, contact Tracy Middleton as
soon as possible.
Criminal Background Checks:
Clinical agencies (i.e. practica and internship sites) utilized by the Department of Health
Sciences may require criminal background checks and/or drug testing prior to acceptance
of the student into the practica/internship site. Students who do not pass the criminal
background check and/or drug test may be unable to attend a practica/internship site and
therefore may be unable to complete their program of study. Any fees or costs associated
with background checks and/or drug testing are the responsibility of the student.
Health Insurance:
Beginning August 7, 2006, the University System of Georgia is implemented a systemwide health insurance policy (GSG SHIP) for all students enrolled in academic programs
that require proof of health insurance. Most Health Science practicum sites require health
insurance. Students who already have health insurance may access the Pierce & Pierce
website to determine if they qualify for a waiver by this company. You may link to this
website from the ASU Student Affairs web page. Proof of health insurance will be
required of all Health Sciences practica and internship students.
Liability Insurance:
Liability Insurance must be purchased before the student goes onto the practicum site. To
obtain liability insurance, go to the cashier’s office in Victor Hall. The cost of the
insurance is approximately $16 per year. After paying for the insurance, bring the
payment receipt to the administrative secretary in the Health Sciences Department. The
administrative secretary will submit your name to be added to blanket liability policy.
Medical Report:
Each student must submit a completed College of Health Professions Medical Report
form for Faculty and Students (this form can be found in the BHS practicum guidelines).
Any qualified healthcare provider may complete this form.
Signature
Date
Technical Standards for the Department of Health Sciences
In addition to the academic requirements for your degree program, there are core
performance standards required for its completion. These standards are necessary to
obtain employment in the degree fields:
1. It is essential that the student must behave in a professional manner. The
student must not, in any fashion, cause disruption to the department, faculty, fellow
students or clients. Furthermore, the student must have the ability to behave in an ethical
manner, have the ability to demonstrate good judgment, maturity, sensitivity, emotional
stability, and establish effective harmonious relationships with faculty, fellow students
and clients.
2. It is essential that the student have the sensitivity and interpersonal skills
sufficient to interact with individuals, families, and groups. Students will be evaluated
using tools such as classroom performance and practicum evaluations, utilized by site and
faculty supervisors, on the basis of their ability to appropriately adapt their manner of
interaction with clients from a variety of social, emotional, cultural and intellectual
backgrounds.
3. It is essential that the student must have communication abilities sufficient for
interaction with others in verbal and written form. It is essential that the students be able
to appropriately adjust presentation/communication style to a level that is compatible
with the communication abilities of colleagues and clients.
__________________________________ _________________
Signature
Date
Letter of Intent
Please write a brief letter of intent outlining why you have chosen to pursue a degree in
Health Sciences and your career goals. This letter must be submitted with your completed
application for the Bachelor of Health Sciences Degree Program. You may write or type
your letter on this page, or attach a separate sheet.
Signature
Date