Student-Application

Name

First NameMiddle NameLast Name

Date of Birth

Date

Are you at least 18 years of age?

YesNo

Social Security Number

Are you a citizen of the United States?

YesNo

Address

Street Address

Street Address Line 2

City / State / Zip Code

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Telephone Number

Drivers License Number

Email Address

example@example.com

How did you hear about Professional Allied Health LLC?

Have you ever been convicted of a felony?

YesNo

Have you ever been convicted of a felony?*

YesNo

If yes, please include specific information with your application on a separate form including the date of felony charge, nature of felony, which court and the final outcome. Include copies of the court

Do you have any physical condition or any other condition(s) which would limit your ability to perform?

NoIf yes, specify those restrictions or accommodations.

Which program are you applying for? (choose one)

PhlebotomyCNAPatient Care TechnicianClinical Medical Assistant

Why are you pursuing this career change?

Do you have any dependents under the age of 18?

NoYes

Do you receive SNAP benefits?

NoYes

Do you receive Families First benefits?

YesNo

Please provide any other information you may feel we need to know in considering your application.

X

Notice

There is a $25 non-refundable application fee.

Did you graduate from high school?

YesNo

Did you obtain a GED or equivalent education?

YesNo

High School Name

City and State

Completion Date

Date

Did you graduate from college?

YesNo

Have you ever completed a program at Professional Allied Health?

YesNo

College Name

City and State

Graduation Date

Date

Name

Relationship

Phone

Name

Relationship

Phone

Emergency Contact Name

Relationship

Telephone Number

Please bring the following:

Social Security Card
Valid State Issued ID
Driver's License
Valid Passport
High School Diploma or Transcript
GED

Name of Student

Student Signature

Date

Program Application

Notice

Education History

References

Emergency Contact

Payment Methods

Thank you for filling out the form once you have clicked submit button this page will send you to a link to schedule your in person tour.