Practical Nursing Admissions Form

SECTION I: GENERAL INFORMATION

Last Name *

First Name *

MI

Any other Names Used:

Last Name

First Name

MI

Street Address

City *

State

Zip Code

Home Telephone *

Email *

Cell Phone

Social Security Number (SSN)

Date of Birth

Gender

Male

Female

Adonis College Of Nursing is strongly committed to Equal Opportunity and does not disciminate no the basis of race, color, religion, sex, national origin, age, veteran status, disability, marital status, or sexual orientation.

SECTION II: PERSON TO BE NOTIFIED IN CASE OF EMERGENCY

Last Name *

First Name *

Relationship

Phone

Last Name

First Name

Relationship

Phone

SECTION III: TRANSPORTATION INFORMATION

Do you have Reliable Personal Transportation to and from classroom and Clinical Site?

Yes

No

SECTION IV: CLASS TIME PREFERENCE

Do you have Reliable Personal Transportation to and from classroom and Clinical Site?

Daytime

Evening

Either

SECTION V: ACADEMIC INFORMATION

Highest Grade Level Completed

Do you have a High School Diploma or GED Certificate?

Yes

No

Have you Completed the nursing training assistant course?

Yes

No

Have you obtained a CNA Certification?

Yes

No

Are you currently enrolled in school?

Yes

No

If yes, School Name

Address

City

State

Zip Code

Current or Previous Cumulative GPA

SECTION VI: FINANCING

What form of payment will you be using?

Cash

Other

No Financial Aid

Tuition refunds area available ONLY in accordance with established college policy. I certify that all the above information is true, without prejudice or misleading information. I further understand and agree to the policies and precedures of Adonis College Of Nursing. I further understand that these policies and procedures can be change without notice. I also grant permission for my pictures to be used on the website or in printed materials. I further agree to pay in full all fees due and further authorize this signature to be on file for use in future credit card authorizations for the payment of fees. I certify that I have received a copy of the catalog and understand that is is updated without notice. I also understand it is my responsibility to read it and abide by its rules, policies, and procedures of this institute.

I DO CERTIFY THAT THE INFORMATION IN THIS APPLICATION IS COMPLETE AND ACCURATE. FAILURE TO BE TRUTHFUL WILL INVALIDATE THIS APPLICATION.

African American	Asian/Pacific Islander
Caucasian	Hispanic
Other