I hereby apply for enrollment in Daymar College subject to the provisions of the College's current catalog. The information on this Application for Admission is accurate, complete and true and any inaccurate, incomplete or false statement will entitle the College to deny admission to me.

To complete a paper copy of this application, click here.

*Fields with a star are required.

Personal Information

Campus Location *
-- Select a Campus -- Louisville Campus Newport Campus Online Campus Owensboro Campus Paducah Campus
First Name *
Middle Name

Last Name *
Maiden Name

Address *
City *

State *
Zip *

Home Telephone *
    Cell Phone
   
Work Phone
    Ext

Primary Email Address *
Other Email Address

Gender *
Gender Female Male

Date of Birth *
01 02 03 04 05 06 07 08 09 10 11 12	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Driver's License Number
Driver's License State
Emergency Contact Name *
Phone Number *
    Relation to Applicant *
Emergency Contact Address *
City *
State *
Zip *

Responses to the following questions are voluntary and are used for state reporting purposes only.

  Veteran Yes No
Disabled
Yes No
Citizen
Yes No If no, Alien No.
Marital Status
-- Select One -- Single Separated Married Divorced Widow Race
-- Select One -- African American White (Caucasian) Hispanic Other Other Race

Transportation Information

Select all that apply
(hold ctrl to select more than one)
-- Select -- Bicycle Bus Fellow Student Friend Motorcycle My Car Relative Taxi Walk Other Other Transportation

Academic Information

Program of Interest *
>
Class Time Preference *
-- Select -- Afternoon Evening Morning Weekend Online Highest Level of Previous Education *
-- Select -- High School Graduate GED Some College College Graduate Name of High School Attended
Address
City
State
Zip
Date of Graduation
Date of GED Test
Testing Center

Name of Previous College
Address
City
State
Zip


Name of Previous College
Address
City
State
Zip

Admission to, employment by and promotion at Daymar College shall be on the basis of merit, and there shall be no discrimination on the basis of race, color, creed, sex, handicap, or national origin. Daymar College provides equal opportunity to all persons.

Applicant's Initials *

**Applicants must be licensed registered nurses.