Student Application Form

* = Required Information

Applicant Information

Name *

First

Last

Date *

Address *

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Phone Number *

Cell Phone

Email *

Gender

Male

Female

Are you a citizen of the United States?

Yes

If no, are you authorized to work in the U.S.?

Yes

Have you ever worked for this company?

Yes

If yes, when?

Have you ever been convicted of a felony?

Yes

If yes, explain:

Education

High School

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

From

Did you graduate?

Yes

College

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

From

Did you graduate?

Yes

Emergency Contact

Name *

First

Last

Relationship *

Phone Number *

Cell Phone

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Name

First

Last

Relationship

Phone Number

Cell Phone

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Class Information

Please check your preferred class schedule *
Day Evening Weekends

Fees and Disclosure

I certify that my answers are true and complete to the best of my knowledge.

I understand that false or misleading information in my application may result in my rejection into the nurse aide-training program. A $50.00 nontransferable/nonrefundable fee is due upon completion of this application. Fees must be paid in full by the first day of class. All fees are due prior to clinicals. The information in this application can be used to complete a background check; if you have been convicted of any violent crime, it can affect your acceptance into the nurse aide program. Attendance is mandatory. You can fail the class for tardiness in excess of 30 minutes. A TB test and physical is mandatory and is due prior to the start of clinicals. Boschulte's Pride Health Center and Learning Center reserves the right to change or cancel any class.

Signature *

Date *