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Home
News & Blog
About
History
Why GMC?
Accreditation & Approvals
FAQ
Video Tour
Programs
Substance Abuse & Addiction Counseling
Healthcare Administration
Medical Assistant
Pharmacy Technician
Health Claims Examiner
Phlebotomy Technician I
Continuing Education (CEU)
CPR & First Aid Courses
Admissions
Admissions Process
Request Info
Financial Aid
Contact
Location & Hours
Request Info
Job Opportunities
Student Questionnaire Form
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Student Questionnaire Form
Please Note: This questionnaire is not an enrollment application.
Name
(Required)
First
Last
Birthdate
(Required)
MM slash DD slash YYYY
Gender
(Required)
Please Select One
Male
Female
Prefer Not To Specify
Other
Phone
(Required)
Email
(Required)
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
What program(s) are you interested in?
Medical Assistant
Health Claims Examiner
Pharmacy Technician
Phlebotomy Technician
Healthcare Administration (AOS Degree)
Substance Abuse & Addiction Counseling (AOS Degree)
How did you hear about Galaxy Medical College?
Friend
Drive / Walk-By
Facebook
Instagram
Twitter
Website
Other
Other
(Required)
Do you have a high school diploma or GED?
Yes
No
Can you provide proof of graduation?
Yes
No
Do you have a social security card?
Yes
No
Are you a U.S. citizen or permanent resident?
Yes
No
Have you ever been convicted of a felony or misdemeanor?
Yes
No
If yes, what year?
(Required)
Please select a year!
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
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
What is your level of education?
Some High School
High School Diploma / GED
College
Other
Are you currently attending any other schools?
Yes
No
What is your primary language?
Are you comfortable reading and writing in English?
Yes
No
Are you currently working?
Yes
No
When can you begin school?
Immediately
Within 3 Months
Within 6 Months
What is your preferred schedule?
Morning
Evening
Weekend
Will you seek employment upon graduation?
Yes
No
Do you prefer working alone or with others?
Alone
With Others
Both
On a scale 1-10, rate your desire to attend school:
Choose one please
1
2
3
4
5
6
7
8
9
10
