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VIP Student Intake

VIP Identification Questionnaire

"*" indicates required fields

Section 1: VIP Contact Information

1.1 Full name of VIP (including title, e.g. Dr., Hon.)*

1.2 Email address*

1.3 Phone number (note preferred: mobile / office)*

1.4 Current occupation and job title*

1.5 Employer or organization*

1.6 Banner ID (if known)

Section 2: VIP Qualification

2.1 Why does this person qualify as a VIP? Check all that apply.*

Major donor or philanthropic partner

Elected official or government leader

Alumni of distinction

Corporate or industry executive

Community or civic leader

Board member, trustee, or advisory council member

Celebrity, athlete, or public figure

Relative of a current VIP, donor, or university leader

Other (specify below)

2.2 Describe the specific reason for VIP status*

2.3 Who identified or referred this VIP?

2.4 Existing relationship with the institiution

Section 3: Academic Interest

3.1 Specific degree program of interest*

3.2 Intended start term*

3.3 Is the VIP applying for themselves or on behalf of someone else (child, relative, employee)?*

3.4 If on behalf of someone else, applicant's name and relationship to the VIP*

Section 4: Scholarship

4.1 Will the VIP (or their applicant) receive a scholarship?*

Yes

No

Pending review

4.2 If yes, what type of scholarship?*

Chancellor’s

Dean’s

Endowed

EM Partnership

4.3 What does the scholarship cover? (check all that apply)*

Tuition

University fees

Books / course materials

Housing

Other: ____________

Other:*

4.4 Scholarship name (if endowed, name of the fund or donor)*

4.5 Award amount and duration (e.g., $10,000 per year, 4 years)*

Section 5: Points of Contact

5.1 Name of primary point of contact (POC) for this VIP*

5.2 Primary POC's title and department*

5.3 Primary POC's email address*

5.4 Primary POC's phone number*

5.5 Name of secondary POC for this VIP

5.6 Secondary POC's email address

5.7 Secondary POC's phone number

5.8 Preferred method of contacting the VIP (email, phone, through an assistant)*

5.9 Additional notes or special instructions

Completed by*

Date*

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URL

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Online or On Campus

Online or On Campus Old

Online

On Campus

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This program is designed for registered nurses looking to advance their degree. A valid, unencumbered RN license is required to apply.

RN License Confirmation(Required)

I currently hold a valid RN license

Don't have your RN license yet? Explore other Regent programs.

High School Graduation(Required)

Are you an employee or the spouse/dependent of an employee?(Required)

Employee

Spouse/Dependent

Email Address(Required)

Company(Required)

Agency(Required)

Employee's Company(Required)

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Company Email Address(Required)

Agency Email Address(Required)

Employee's Company Email Address(Required)

Employee's Agency Email Address(Required)

Employee's First Name(Required)

Employee's Last Name(Required)

Employee's First Name(Required)

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Your Email Address(Required)

Your Email Address(Required)

First Name(Required)

Last Name(Required)

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I live outside the US

Address(Required)

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City(Required)

State(Required)

Zip Code(Required)

Phone(Required)

I live in Canada

I live in Canada

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Agent GUID

Agent's Notes

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By entering my first and last name above and clicking “Learn More” below, this shall constitute my electronic signature and I expressly agree that Regent University or its third party service providers may call or text me for marketing purposes at the number I provide above, including through the use of an automatic telephone dialing system and/or artificial or prerecorded voice or message according to the TCPA Terms & Conditions below. Providing this consent is not required to obtain any good or service.

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EQUAL OPPORTUNITY POLICY FOR STUDENTS Regent University does not discriminate on the basis of race, color, sex, national or ethnic origin, disability, age or veteran status in admissions, treatment or access to its programs and activities, or in the administration of educational policies, scholarships, loan programs, athletics or other University programs. In addition, Regent does not discriminate based on religion, except as necessary to comply with Regent’s Standard of Personal Conduct and Statement of Christian Community and Mission. Telephone Consumer Protection Act (TCPA) Terms & Conditions By submitting your information and telephone number through the above “Request Information” form and clicking “Learn More” to request information (“Inquiry”), You agree that Regent University (“Regent”) and all of its related corporate entities, agents, independent contractors, assigns, and successors may call You through the use of any dialing equipment (including a dialer, automatic telephone dialing system, and/or interactive voice recognition system) and/or artificial or prerecorded voice or message, even if You are charged for the call or message. You expressly agree that such automated calls may be made by Regent and/or its related corporate entities, agents, independent contractors, assigns, and/or successors to any telephone number (including numbers assigned to any paging, cellular, or mobile service, or any service for which You are charged for the call) You have provided previously or may provide in the future in connection with Your Inquiry. You expressly consent to such automated calls. With such consent, You specifically waive any claim You may have against Regent and/or its related corporate entities, agents, independent contractors, assigns, and/or successors for the making of such calls, including any claim under federal or state law and specifically any claim under the Telephone Consumer Protection Act, 47 U.S.C. § 227. You also expressly agree that this provision applies to the use of text messaging. You expressly consent to the receipt of text messages from Regent and all of its related corporate entities, agents, independent contractors, assigns, and successors at any telephone number (including numbers assigned to any paging, cellular, or mobile service, or any service for which You are charged for the call) You have provided previously or may provide in the future in connection with Your Inquiry. You are not required to accept this consent to obtain any good or service.

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