Application for Admission

This form is to be used ONLY if you have spoken to our school staff and determined about attending the school. If you have general questions please call the school first. After filling out this form a student must come in person to take an entrance test, pay registration fee $250 and have driver's license and social security card on hands.
Personal Data:

First Name:                              Middle Name:                          Last Name:
              

Email Address:

Social Security Number:             DOB:
       

Current Address, Line 1:

Current Address, Line 2:

Home Phone Number:              Cell Phone Number:                 Work Number:
           
 

Education: (List all schools, certificates earned and universities that you have attended).

Institution:                                             City:                                       State:
            

            

            

            

            

Work Experience: (List below your last 3 employers, most recent first).

Date:             Employer Name:                   Employer Address:                  Position:
(MM/YY) 
            

Duties:

Date:             Employer Name:                   Employer Address:                  Position:
(MM/YY) 
            

Duties:

Date:             Employer Name:                   Employer Address:                  Position:
(MM/YY) 
            

Duties:

References:

Full Name:                    Occupation:            Address:                        Phone Number:              Years Known:
                 

Full Name:                    Occupation:            Address:                        Phone Number:              Years Known:
                 

Full Name:                    Occupation:            Address:                        Phone Number:              Years Known:
                 

Think about what this career means to you. Then answer the following questions:

1) Why do you want to take the selected training?

2) Why have you chosen our school and program?

3) How did you hear about our school and the programs we offer?

4) What skills and strengths to you bring to the health care field?

5) What are your long term goals?