Pre-Enrollment Form

Professor Renee Roeschen-Bradley, Program Director
916 691-7452 or 916 247-5767~ roeschr@crc.losrios.edu

To be eligible for enrollment in the program, the student must have completed AH 110, AH 124, and Biol 100 or 102 with grades of C or better. Complete the Pre-Enrollment Form if you have completed the above courses.

This is an online program. Students must have access to the internet, have an e-mail account, and be familiar with word processing, retrieving and attaching electronic documents, and using the world wide web.

First Name	Last Name

7-Digit Student ID

Mailing Address

City	State	Zip

Email Address

Employed in Healthcare?	YesNo

Signature (Type your full name)

Courses you have completed with a grade of "C" or better:
AH 110 Medical Language for Healthcare Providers
Yes No
AH 124 Pharmacology for the Healthcare Professional
Yes No
BIOL 100 Human Anatomy & Physiology
Yes No
Are you pursuing the A.S. Health Information Technology Degree?
Yes No
Are you pursuing the Health Information coding Specialist Certificate?
Yes No