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Application for admission & financial aid

Division of Adult and External Studies (DAES)
Degree-completion and certificate students only

If you are not an adult, degree-completion student (you are a first-year, transfer or high school student), please complete the traditional, first-year student Application for Admission & Financial Aid.

Note: Goshen College does not offer online courses at this time. All courses are taught on the Goshen College campus.

Untitled Document

Desired program

	R.N. to B.S.N. Completion Track
	Organizational Leadership Program

Personal information

Last name:

First name:

Middle initial:

Preferred name:

Former name:

Gender:

Male
Female

Address:

City:

State:

ZIP:

Home phone:

Home E-mail:

Social Security number:

Birthdate:

Citizenship:

U.S.
Other

Marital Status:

	Married
	Single
	Divorced
	Widowed
	Status as of date:
	Spouse name:

Ethnic Background:
(as requested by
U.S. Dept. of Education)

	African-American/Black
	American Indian/Alaskan
	Asian/Pacific Islander
	Hispanic
	White, non-Hispanic
	Other:

Employment information

Employer:
Work phone:	Ext:
Work E-mail:
Fax:
Position:
No. years at current employer:
Address:
May we contact you at work?	Yes No
Best time to contact you:

Educational background

High school

Name of school:
City/State:
Graduation date:

College

Name/City/State of College	Dates attended From (mo./yr.) to (mo./yr.)	Credit hours earned	Degree/ Major
	–
	–
	–
	–
	–

Have you served in the U.S. Military?

Yes
No

If "Yes" you may be eligible for additional college credits if you supply us with a certified copy of your DD214 form.

References

List two adults, other than family members, whom we may contact concerning your qualifications for admission:

Reference #1

Name:
Street:
City:
State:
ZIP:
Phone:

Reference #2

Name:
Street:
City:
State:
ZIP:
Phone:

B.S.N. applicants only
(Skip this section if you are NOT applying for the B.S.N. completion track)

College/School of Nursing:
City:
State:
	Diploma in Nursing Associate of Science in Nursing Degree
R.N. License #:	State:
R.N. License #:	State:
Number of years experience as R.N.:
Date of last CPR recertification:
Personal liability (malpractice) insurance: (required for clinicals):	Yes No
Company:
Policy #:
Expiration date:

Professional reference

Name:
Address:
City:
State:
ZIP:
Phone:

(All applicants)
I am applying for:

	Admission only (no financial aid). Click here to skip the financial aid section -- or, scroll down past it.
	Admission and all types of financial aid for which I am eligible. Completion of the Financial Aid section below and a Free Application for Federal Aid (FAFSA) form is required.
	I have sent the FAFSA to the federal processor on: / / Mailed via U.S. Mail Electronically via www.fafsa.ed.gov

Financial aid

A) Family information

Number and ages of dependent children living with you:

Number:
Ages:
List any additional child care costs caused by your enrollment in this program:	$ per month

If someone in your immediate family will be attending college at the same time you are, please complete the following:

Name	Relationship	College Name	Enrollment Status
			Full-time Part-time
			Full-time Part-time
			Full-time Part-time

B) Financial sources

List any outside sources (not including Federal Stafford loans and/or Federal and State grants) from which you will receive money for this program.

Source	Amount	Yearly	Monthly	Per course	% of tuition
Employer Name:
VA benefits
Church/Conference Name of church or conference:
Other Specify:

C) Statement of Educational Purpose/Certification on Refunds and Default

I certify that I do not owe a refund on any grant, am not in default on any loan, and have not borrowed in excess of the loan limits, under the Title IV programs, at any institution. I will use all Title IV money received only for expenses related to my study at Goshen College.

D) Statement of registration status

I certify that I am registered with Selective Service.

I certify that I am not required to be registered with Selective Service because:

	I am female
	I am in the armed services on active duty. (Note: This does not apply to members of the Reserves and National Guard who are not on active duty.)
	I was born before 1960.
	I am a citizen of the Federated States of Micronesia or the Marshall Islands or a permanent resident of the Trust Territory of the Pacific Islands (Paulau).

NOTE: To receive Title IV financial aid you must complete the Statement of Educational Purpose/Certification Statement on Refunds and Default and if required, be registered with Selective Service.

Christian faith at Goshen College

At the time of application we remind you that Goshen is a Christian college that emphasizes the development of a strong and mature Christian faith and a commitment to the church. You will encounter the Christian faith as it is held and lived by our faculty and the majority of Goshen students.

Other information

(optional, used for statistics only)

Church affiliation:
Denomination conference (if Mennonite):
Congregation address:

Signature

I have reviewed this application and, to the best of my knowledge, find the information to be complete and accurate. Download, print, sign and mail this Signature Verification Form (.Pdf). An application fee of $35 must accompany the Signature Verification Form before your application will be processed.

Statement of nondiscrimination

Goshen College is in compliance with all applicable federal regulations pertaining to nondiscrimination on the basis of sex, race, color, national or ethnic origin, age and handicap in its recruitment, admission, educational, athletic, financial aid and employment policies and programs.

Goshen College 1700 South Main Street, Goshen, Indiana 46526
Toll free: 1 (800) 348-7422 • Local: (574) 535-7000 • E-mail: info@goshen.edu

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