YIEP Student Intake Form "*" indicates required fields LinkedInThis field is for validation purposes and should be left unchanged.PERSONAL INFORMATIONPlease identify the program(s)/area of study that you are interested in*Select >BS in Legal StudiesBS in BusinessBS in Behavioral Science/Human ServicesBS in Cyber SecurityBS in Data ScienceMS in Clinical Mental Health CounselingMS in Data ScienceMA in Educational LeadershipMaster of Business Administration - MBAMaster of Healthcare Administration - MHAOtherWhen do you plan to start? MM slash DD slash YYYY Consent* I agree.The University, and its accrediting body, require a 4-DAY ON-SITE RESIDENCY SEMINAR for all MSCC students. This is a requirement of all students, and there are no exceptions to appear IN PERSON IN NEW YORK. Since COVID began, Bellevue has allowed the students to appear on Zoom, but as of the YIEP cohort starting August 2026, Residencies will return to in-person. The 4-day residency is typically held from Sunday through Wednesday, the first four days of the cohort in the FIRST AND SECOND YEARS OF THE PROGRAM from 9AM EST - 4PM EST with a 45-minute break for lunch. In order to apply for State Licensure, the student must take and pass a national exam, offered by NBCC, National Board for Certified Counselors, please see www.nbcc.org. The examination is not required for graduation. The exam is given in April and October of each year, at various sites throughout the United States. Bellevue University facilitates the exam. Please discuss with your advisor when you should take the exam. YIEP and BELLEVUE UNIVERSITY will work closely with the student to obtain a placement for the Practicum and Internships necessary in the second year of the program (and to date we have been successful), however, such placement is ultimately the responsibility of the student.TitleRabbiMr.Mrs.Ms.Name* First Middle Last Maiden Name (or other) Last 4 digits of your Social Security NumberDate of birth MM slash DD slash YYYY Mailing address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Preferred contact method: Email Home # Work # Cell # Best time to call: (Days/Time)Home phoneWork phoneCellFaxEmail address typeHomeBusinessOtherEmail Are you a U.S. Citizen? Yes No Which Passport(s) do you currently hold? U.S. Canada U.K. South Africa Israel Other Gender Male Female Marital StatusSingleMarriedDivorcedSeparatedWidowedSECTION 2 - HIGH SCHOOL INFORMATION (Undergraduate Only)High School NameCity & StateGraduation date MM slash DD slash YYYY High School Home School (City & State) GED (City & State) SECTION 3 - ACADEMIC HISTORYHave you attended Bellevue University previously? Yes No Dates of Attendance MM slash DD slash YYYY Which best describes the type of applicant you are:High School StudentTransfer StudentFirst Year StudentUndergraduate Accelerated CohortGraduatePlease list all colleges/universities, Yeshiva/Seminary attended.Full Name of InstitutionStateDate AttendedDegree (AAS, BS, BA, etc.)Credits EarnedGraduated? Add RemoveAll degree-seeking students are required to have official transcripts from each high school/college/university/Yeshiva/Seminary sent directly to the YIEP before the start of the program.Other sources of academic credit (please check all that apply): Corporate Training No Corporate Training YIEP Transfer Credit CLEP/DSST/AP License (e.g., R.N., EMT, Insurance, Real Estate, Pilot, Police, etc.) CLEP/DSST/AP License (e.g., R.N., EMT, Insurance, Real Estate, Pilot, Police, etc.) Professional Certification Other Professional CertificationOtherHave you been suspended from another college/university within the past five years? Yes No What institution and whenSECTION 4 - EMPLOYMENT Employer/Company |EmploymentEmployer/CompanyPositionAddress/City/State/ZIP/CountryDates employedFT/PT Add RemoveSECTION 5 - MARKETING INFORMATIONHow did you hear about YIEP? YIEP advertisement Radio Newspaper Television Word-of-mouth Website Direct Mail Other OtherSECTION 6 - FINANCIAL PLANNING SECTIONPlease let us know which payment plan(s) you intend to use (please check all that apply): Financial Aid (grants, loans, scholarships) Corporate Reimbursement Direct Corporate Billing Corporate Tuition Assistance Military T.A. Veterans Benefits (G.I. Bill, Voc. Rehabilitation Student Payment (cash, check, credit card) Other SIGNATURE SECTION/VERIFICATION OF INFORMATIONI certify that I have read this form and that all information submitted is true and accurate. Bellevue University does not discriminate on the basis of sex, age, race, religion, color, national orgin, or disability in its admission, employment, and education programs or activities.Signature of StudentDate MM slash DD slash YYYY Payment* I would like to pay the $1,000 YIEP registration fee now I have already paid the registration fee Other Please explain how you plan on paying*Registration Price: Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Security Code Cardholder Name CAPTCHA
