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 _________________________________