Name
Please enter your name as it appears on your passport.

First Name / Given Name

Middle Name

Legal Last Name

Preferred First Name

Maiden Last Name

Current Phone
Please enter your best phone number for contact from La Roche University.

Current Phone Number

Email
Please enter your best email address for contact from La Roche University.

Email Address (Format: x@x.xx)

Home (Permanent) Address
Please enter your permanent address in your home country.

Address Line 1

Address Line 2

Address Line 3

City

US State/Canadian Provence 

Postal Code

Country

Current Address
Please enter your current address if different from your home address above.
All documents will be mailed to this address.

Address Line 1

Address Line 2

Address Line 3

City

US State/Canadian Provence 

Postal Code

Country

Citizenship and Visa Information

Birth Date (Format: mm/dd/yyyy)

Are you a U.S. citizen or permanent resident?

Country of Birth

Country of Citizenship

Personal Information

Social Security Number
*Must be provided if you are a US citizen/permanent resident who is receiving/applying for any financial assistance.

Gender

Race
(You may check more than one.)

Ethnicity

Veteran Status

Are you a veteran of the United States military service?

Are you an active duty veteran who has suffered service-related injury or illness, or are you the spouse or dependent of an active duty veteran who has suffered service-related injury or illness?

Are you the spouse or dependent of a service member on active duty?

Are you the spouse or dependent of a veteran who is deceased?

Are you receiving any veteran's benefits?

Criminal History

Have you ever been convicted, pled guilty or no contest to a crime other than a summary traffic offense?

If "Yes," please describe the details (maximum 100 characters)

Enrollment & Housing

Planned Enrollment Year

Planned Enrollment Term

Enrollment status (Full-time only): 

What type of housing do you need?

Will you be applying for financial aid?

Have you applied to La Roche University before?

How did you hear about La Roche University?

Prerequisites
Applicants for the ELMSN Program are required to provide proof of completion of the following prerequisites with a grade of "C" or better.

1. Human Anatomy & Physiology I (with lab component)
2. Human Anatomy & Physiology II (with lab component)
3. Microbiology (with lab component)
4. Chemistry