NamePlease enter your name as it appears on your passport.
First Name / Given Name
Legal Last Name
Preferred First Name
Maiden Last Name
Current PhonePlease enter your best phone number for contact from La Roche University.
Current Phone Number
EmailPlease enter your best email address for contact from La Roche University.
Email Address (Format: firstname.lastname@example.org)
Home (Permanent) AddressPlease enter your permanent address in your home country.
Address Line 1
Address Line 2
Address Line 3
US State/Canadian Provence
Current AddressPlease enter your current address if different from your home address above.All documents will be mailed to this address.
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
Social Security Number*Must be provided if you are a US citizen/permanent resident who is receiving/applying for any financial assistance.
Is English your native language?
Race(You may check more than one.)
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?
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?
PrerequisitesApplicants for the ELMSN Program are required to provide proof of completion of the following prerequisites with a grade of "C" or better.