* - Denotes Required Fields.

Name: Mr. Mrs. Ms.   *Family/Surname:

*Given/FirstName: Middle Name:

Marital Status: Single Married Separated Divorced    Preferred Name:

*Date of Birth (mm/dd/yy):  *Place of Birth (city/state/country):

*Language(s) Spoken at Home: Gender: Male Female

Optional Personal Data for U.S. Citizens

Ethnicity: American Indian or Alaskan Native Black, Non-Hispanic Hispanic Asian or Pacific Island Caucasian Other (please specify):

Citizenship (please check only one): *Country of Citizenship :

U.S. Citizen - Social Security Number:
Non-U.S. Citizen - Current Visa Status: - U.S. Permanent Resident (Please attach copies of card's both sides) - Alien Number:
Refugee

Current Mailing Address:

Street/Address/P.O. Box:

District/Province: City:

State: Zip Code: Country:

Telephones: Day: Evening: Mobile:

Effective Dates - From (mm/dd/yy): to (mm/dd/yy):

Note: All applicants must list their permanent home address if different from their current mailing address.

Permanent Address:

*Street/Address/P.O. Box:

District/Province: *City:

*State: Zip Code: *Country:

Telephones: *Day: Evening: Mobile:

E-mail Address: Home Work Campus Personal *

*Name of Planned Degree Program: * Name of Planned Concentration/Specialization:

Student Number (if previously attended Keiser University):

How, where or from whom did you hear about Keiser University?

Note: One copy of your undergraduate official transcript is required and must be remitted to Keiser University Registrar at the address below:

The Graduate School • 1900 W. Commercial Blvd.• Ft. Lauderdale, Florida 33309 • 1-888-753-4737

Keiser University is an equal opportunity/affirmative action educational institution

Please list all colleges/universities you are currently attending or in which you have been enrolled:

Academic honors, prizes or scholarships you have received or honor societies to which you have been elected:

Professional organizations in which you currently hold membership(s):

Title or description of any thesis, research report, patent or other publications (use separate sheet, if necessary):

Three letters of recommendation, two from healthcare professionals, are required. Please list below the names of the individuals from whom you have requested recommendations. If you are a current student at Keiser University, please list two faculty members, who know you and can evaluate your academic work:

*1. *2. 3.

Please describe your background (e.g., coursework, professional and research experience, etc.) as it pertains to your area(s) of interest at Keiser University:

I certify that the statements made in this application are true to the best of my knowledge. if admitted, I agree to abide by the rules and regulations of Keiser University.

*Name/Electronic Signature
By typing your name you have created an electronic signature as legally binding as your handwritten signature.

University Enrollment Policies and Procedures:

GENERAL TERMS

Each student is accepted with the understanding that he/she has registered for the entire course of study at the graduate level. The student agrees to report to Keiser University, located in Florida, and/or to log on online on or before the program starting date, and maintain regular attendance at the University during each term registered for and abide by all the Rules and Regulations of the University. The University reserves the right to dismiss any student for maintaining poor academic standing, excessive absences, failure to comply with the regulations of the University as stated in the current literature, or for non-payment of tuition and fees when due. A late charge of five (5) dollars is added to any invoice ten (10) days or more overdue. Students are liable for all late fees, reasonable attorney’s fees and all other costs and charges necessary for the collection of unpaid fees. Students must supply personal items, such as textbooks, pens, paper, and notebooks. Students are held responsible for all misuse and/or breakage of equipment in the University’s facilities.

GENERAL POLICY

University policies have been formulated in the best interest of students and the University. Changes in University policies are rarely made during a school year, since plans for each season are made well in advance. However, the University reserves the right to make changes in tuition, fees, refund policy, curricula or any phase of its programs, where, in the opinion of the administration, students and/or the University will benefit. Such changes may be made without further notice. The University also reserves the right to cancel any classes which do not have a minimum number of five students enrolled. Courses which are delayed are rescheduled within 16 weeks of the original date or the University will make a full refund of all monies paid to the University for them. After successful completion of the program, students receive their graduate degree from the University. Although Keiser University provides employment assistance, it cannot promise or guarantee employment.

ADMINISTRATIVE PROCEDURES

Occasionally, students have concerns and/or problems that need to be addressed. Students can confidentially discuss their problems at any time with their instructors, the Student Services Department or anyone on staff at the University. Additionally, Campus Presidents maintain an opendoor policy to meet student needs. If the administration has to take disciplinary measures against a student, he/she may appeal the decision to the Grievance Committee, which is made up of impartial staff member, and a student representative. If a student dispute is litigated, and the student receives an unfavorable decision, the University will be entitled to any reasonable attorney’s fees incurred in the legal proceedings.

ARBITRATION

It is agreed that, in the event the parties to this agreement are unable to amicably resolve any dispute, claim and/or controversy arising out of or relating to this agreement, or if a claim is made by either against the other or any agent or affiliate of the other, the dispute, claim and/or controversy shall be resolved by arbitration administered by the American Arbitration Association under its Commercial Arbitration Rules. If this chosen form or method of arbitration is unavailable, or for any reason cannot be followed, a court having jurisdiction hereunder may appoint one or more arbitrators or an umpire pursuant to section 682.04 F.S. Each party shall have the right to be represented by an attorney at any arbitration proceeding. The expenses and fees of the arbitrator(s) incurred in the conduct of the arbitration shall be split evenly between the parties to the arbitration. However, if the University prevails in the arbitration proceeding, the University will be entitled to any reasonable attorney’s fees incurred in the defense of a student’s claim(s). Venue for any proceeding relating to arbitration of claims shall be in the county wherein the institution is located. This agreement cannot be modified except in writing by the parties.

GRADUATION REQUIREMENTS

In order to graduate from Keiser University with a graduate degree, students must (1) Successfully complete all requirements for graduation. A complete listing is found in the Keiser University catalog; (2) Complete all documentation, records and files as necessary; (3) Fulfill all financial obligations to the University.

CANCELLATION AND REFUND POLICY

Tuition and Fees Disclosure

Tuition is computed on the assumption that a student will remain throughout an academic year. Since a place in class has been reserved, tuition is only refunded in accordance with the University’s Withdrawal Policy. Students withdrawing from the University must comply with the proper clearance procedures as outlined in the catalog. Refunds and/or reductions in indebtedness are made solely at the option of the University for withdrawals necessitated by conditions beyond the student’s control, such as an emergency acceptable to Keiser University. Refunds and/or reductions in indebtedness are processed after all required approvals are documented on the Withdrawal Form. Students are obligated for all charges (tuition/ fees/books/supplies/ laptops) for the term and/or semester they are currently attending, plus any prior account balance. A semester equals two terms (16 weeks), with one term equaling eight (8) weeks of instruction. An administrative fee of $100.00 is charged when a student withdraws prior to the end of a term and/or semester in which he/she is enrolled. Students, who have withdrawn and wish to reenter, are charged a $150.00 reentry fee.

Return of Title IV Funds (R2T4)

A pro-rated portion of any Federal Tile IV funds received are returned to appropriate programs for students who withdraw prior to the completion of a term in the semester that is prior to reaching the 60% point of a semester. The formula for Return of Title IV Funds (Section 484B of the Higher Education Act) also specifies the order in which funds are to be returned to financial aid programs. The return of Title IV funds follows a specific order: (1) FFEL/Direct Stafford Unsubsidized Loan; (2) Subsidized Loan; (3) FFEL/Direct Grad Plus; (4) Other Title IV Program (Not FWS).

Cancellation/Withdrawal Calculation

Withdrawal at any time from the date of a student’s registration to the day before the first scheduled day of the semester: The University retains a Withdrawal Fee of $100 and the Application Fee of $50.00 (1) Withdrawal at any time during the first week of the semester and/or term: 90% refund of tuition only. (2) Withdrawal at any time during the second week of the semester: 85% refund of tuition only. (3) Withdrawal at any time during the third week of the semester and/or term: 80% refund of tuition only. (4) Withdrawal at any time during the fourth week of the semester and/or term: no refunds. 1. Any funds paid for supplies, textbooks, and/or equipment, which can be and have been returned to Keiser University, will be refunded to graduate students who withdraw prior to the start of the term and/or semester upon return of said items, which can be resold. The University reserves the right to determine if above-mentioned items are returnable. 2. All Registration Fees are refunded, if a student is not accepted into his/her program. Students must notify the University in writing of cancellation. All monies paid by an applicant are refunded if cancellation occurs within three business days after signing the herein outlined Keiser University Enrollment Policies and Procedures (Agreement), All Application and Registration Fees in excess of $100 are refunded to the student. Refunds are made within thirty days from the date of determination of a student’s official withdrawal date. All balances owed the University due to the return of Title IV funds or withdrawal calculations or a balance due at time of graduation are billed to the student. No official academic transcripts are issued to any student who owes a balance to the University at the time of the request. Upon payment of the outstanding sum or debt, official transcripts may be issued.

NOTICE TO APPLICANT

I acknowledge that I have read this Keiser University Enrollment Policies and Procedures (Agreement) in its entirety as printed on this document, that I understand and agree to the provisions listed and that I have received a copy of the Agreement and its provisions. I understand that if I am accepted as a graduate student, the amount paid with the Keiser University Enrollment Policies and Procedures (Agreement) will be credited toward my Application and Registration Fees upon entrance to the University, and if I am not accepted as a graduate student, all monies, except the Application Fee of $50.00 will be refunded to me. I hereby agree to abide by the terms herein listed and by the regulations and policies of Keiser University as stated in the catalog and published/printed literature. No other arrangements than these will be honored, except those specifically agreed to in writing.

(1) Do not sign this Keiser University Enrollment Policies and Procedures (Agreement) until you read it and/or if it contains blank spaces. (2) You are entitled to a copy of this document at the time you sign it. (3) You may repay your unpaid balance at any time. (4) HOLDER—any holder of this consumer credit contract is subject to all claims and defenses which the debtor could assert against the seller of goods or services obtained pursuant hereto or with the proceeds hereof . Recovery hereunder by the debtor shall not exceed amounts paid by the debtor hereunder. (5) These policies and procedures shall become binding upon acceptance by Keiser University.