Student's Personal Data Sheet

PLEASE NOTE: Your are required to fill out each field. If the field does not apply to you, put N/A in the blank.

Home Information

Name:

Home Address:

City:

State:

Zip Code:

Home Phone:

Home Fax:

Email:

PLEASE NOTE: Your are required to fill out each field. If the field does not apply to you, put N/A in the blank.

Employment Information

Place of Employment:

Work Address:

City:

State:

Zip Code:

Work Phone:

Work Fax:

Work Email:

PLEASE NOTE: Your are required to fill out each field. If the field does not apply to you, put N/A in the blank.

Demographic Data:

Age:

Date of Birth:

Sex:
Male
Female

Martial Status:

Spouse name:
(if applicable)

PLEASE NOTE: Your are required to fill out each field. If the field does not apply to you, put N/A in the blank.

Student Data:

Program:
  DNP     MSN    BSN

Option/concentration:
CANP   FNP   NNP CRNA
PHN/Admin Forensic   PFNP   PNP
Gerontology Nurse Admin   MedSurg
BSN   RN-BSN

Anticipated month/year of graduation:

PLEASE NOTE: Your are required to fill out each field. If the field does not apply to you, put N/A in the blank.

Please check the box (es) below to indicate your ethnicity:

American Indian or Native American

Under-represented Asian (includes any Asian other than Chinese, Filipino, Japanese, Korean, Asian Indian, or Thai)

Asian (not under-represented)

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Other

PLEASE NOTE: Your are required to fill out each field. If the field does not apply to you, put N/A in the blank.

Person to notify in an emergency:

Name:

Relationship:

Phone number:

PLEASE NOTE: Your are required to fill out each field. If the field does not apply to you, put N/A in the blank.

Other Data:

PLEASE NOTE: Your are required to fill out each field. If the field does not apply to you, put N/A in the blank.

CPR Certification:

Expiration date:

PLEASE NOTE: Your are required to fill out each field. If the field does not apply to you, put N/A in the blank.

Primary Language spoken:

Financial Aid Information Request

The UTHSC Office of Financial Aid has asked our College to identify students who might be eligible for the Federal Scholarship for Disadvantage Students. To assist in that process, please read the statements below and indicate which statements apply to you.

attended an inner-city or rural area school where learning opportunities were limited because of fewer resources than those in more affluent areas.

am from a large family who is struggling to provide education for children.

am a married student with limited resources.

am a student who is responsible for the care of someone else, a child, a parent, etc.

other

Financial aid will consider this and other information including declared need in making financial awards for this scholarship.

Click SUBMIT to forward your form to Janet Wood jwood26@nursing.utmem.edu at 901-448-6125 in Student Affairs.