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Complete Health Center Document Upload Submission
Complete Health Center Document Upload Submission
AE Form Web Part
Banner ID:
First Name:
Last Name:
Email:
*
please enter a value
please enter a valid e-mail address
This is the email address we have on file. If you would like to be contacted through a different address, please change this field.
Confirm Email Is Correct:
*
please choose a value
Yes
Contact Phone:
*
please enter a value
please enter a valid phone number
Document Type Submitted:
*
please choose a value
Mental Health Intake
Telehealth-HIPPA
Notes (Optional):
Attach Your Upload:
*
Maximum file size is 2MB. Please submit as a PDF, Word, Excel, JPEG, or PNG file.
By clicking the Submit button below, I hereby give consent to College of the Sequoias to process any forms submitted through cos.edu. Any questions regarding this consent can be directed to me using the email address that I have provided above, in this form.
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Please
stop
and
read
the following message before continuing to the Noncredit application! If you complete this
noncredit application
you
will not
be able to register for a credit course.
Noncredit classes are NOT degree applicable, CSU/UC transferable, or credit certificate applicable.
If you want to be able to take credit classes, please go to the
credit application here
.
Noncredit applications serve our English as a Second Language (ESL) community among other specialized noncredit certificates. Upon completion of your noncredit course(s) a certificate is awarded.
Click here to continue to the Noncredit Application