Agape Angelicum School of Nursing Arts

Application form

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Please submit completed application form with Background Check (free of misdemeanor and felony)
 
IMPORTANT: To all International applicants and students

*Before applying please read, print and sign. Submit this form on your interview date.

Agape Angelicum School of Nursing Arts is committed to students' success. You have 80 hours to accomplish your goal to receive your Nurse Aide license from the Board of Nursing. It is with utmost importance to accept students that are willing to focus on the tasks ahead.

We at Agape Angelicum School of Nursing Arts strive to help you reach your potential to be your best. We expect your full cooperation in working with us. We value a good team players and good work ethics. The following are essential elements to your success.

1.       All "clinical "requirements for the program must be satisfied on the first week of class.

2.       All school policies must be followed (If you have difficulty following policies please reconsider other alternative schools).

3.       Our school has strict uniform policy (If you do not like uniforms please consider other schools that do not require uniforms). Tattoos must be covered and No visible body piercing. Pair of stud earrings is allowed.

4.       The Nurse Aide training program is taught entirely in English. The instructions are delivered in a considerable fast phase. The ability to read and understand written English is therefore extremely important!

5.       Different Skills are taught on different days and are taught before the "clinical phase of training" can begin.

6.       All classroom evaluation tests and assignments must be completed within the 62 hours prior to "clinicals". No students will be allowed to go to clinicals without completing all school required tasks.

7.       No students will be allowed in "clinicals" if skills are not fully mastered.

8.       Attendance is extremely important to your success in the program.

If you do not feel you can accomplish the tasks (with our required 80 hours) or your schedules do not warrant your full focus to the curriculum; please reconsider other programs from other schools that can provide your logistics/and other needs.

We strive to keep our tuition cost low. We also know that is still a considerable amount for most students. By signing our application form, you are agreeing to the above requirements and are able to communicate well in English and have the language skills to attend our school.

Once accepted in the program there will be no refunds.

Students Signature____________________________ Date____________________________

Form revised 12/04/2010

Student Application Form

Enrollment: Month____ Year____Date_____

Legal Name: __________________________

Last First Middle

Address:_______________________________________

Street City State ZIP

Date of Birth ________ Age______Sex__________

Social Security#______-_______-_______

Driver License__________

Evening Phone __-___-__ Cell Phone __ -___-___

Day/Business Phone ___-___-___

E-mail Address_____________________

Previous Education:

University/College/Vocational (Check highest level completed)

___No college or university

___Some college or university, no degree

___Associate degree

___Bachelor’s degree

High School (Check one box)

____High school diploma

High School Name_____________________ State_______

Month ___________ Year__________

____GED certificate Month ______ Year________

____Currently enrolled

 HS Name_________________ State_______

Expected completion Month_____ Year____

____Home taught

 Expected completion Month_____ Year____

____No Diploma or GED and age 18 or over

____No Diploma or GED and under age 18

Note: Students under 18 requires permissions to enroll

parents/guardian signatures needed.

What is your primary reason for attending this school?

____Prepare for employment

____Improve my skills at my present job

____Learn new skills for a better job

____Prepare for a career change

____For my personal interest or self- improvement

____Preparation for college (Nursing etc.)

Employment History

1. Place of employment________________________________________

Address_______________________________________________

Job title_______________________________________________

Dates Employed________________________________________

Wage/Salary___________________________________________

Supervisor’s Name______________________________________

Reason for leaving ______________________________________

2. Place of employment________________________________________

Address_______________________________________________

Job title_______________________________________________

Dates Employed________________________________________

Wage/Salary___________________________________________

Supervisor’s Name______________________________________

Reason for leaving ______________________________________

Personal References (Person who can vouch for your character and work ethics)

1. Name___________________________________ Phone __________________

First Last

Address__________________________________________________________

Street City State ZIP

2. Name___________________________________ Phone __________________

First Last

Address__________________________________________________________

Street City State ZIP

AGAPE ANGELICUM School of Nursing Arts does not discriminate on the basis of race,

color, sex, age, national origin, religion, handicap, Veterans status or any other

characteristic protected by Federal or State Law.

All of the information on this form is confidential and in compliance with the Family

Education Rights and Privacy Act of 1974.

I hereby authorize the administrators of the AGAPE ANGELICUM School of

Nursing Arts an investigation of my past employments, references and

statements contained in this application and release all liability and responsibility

from persons, companies or corporations supplying such information. Further, it

is my understanding that any false statement made by me on this application

shall be grounds for dismissal should I be accepted in the AGAPE ANGELICUM

School of Nursing Arts.

Signature of Applicant _______________________________________

Signature Parent or Guardian (if under age) _________________________

Date _________________________________

Enter supporting content here

For more details:
       Please call 720-470-6563 prior to paying

Agape Angelicum

School of Nursing Arts

www.agapeangelicum.com

5005 W 81st Place Suite 203, Westminster CO, 80031

Tel.  720-470-6563 

Email: AgapeAngelicum@gmail.com

 

Facebook: www.facebook.com/agapeangelicumschool