STUDENT ADMISSIONS APPLICATION
Please Check Program of Interest
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Associate of Applied Science in Healthcare Management
Associate of Applied Science in Information Technology
Associate of Applied Science in Business Management
Associate of Applied Science in Social Work
Associate of Applied Science in Legal Studies
Medical Assistant
Pharmacy Technician Training
Phlebotomy and EKG Technician
Medical Insurance Billing & Coding Specialist (On Campus)
Medical Insurance Billing & Coding Specialist (Online)
Practical Nursing
Nursing Assistant
Practical Nursing Applicants
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Please Select
I did apply to the practical nursing program
I did not apply to the practical nursing program
Applications for practical nursing will only be considered if ACCUPLACER score-s are provided.
Practical Nursing Applicant ACCUPLACER Scores (0 if does not apply to you). If this does not apply to you, please put a "0" in the box. Please place all scores in the box. All ACCUPLACER scheduling and applications should be completed online. ACCUPLACER scheduling: https://infinity-college.square.site/ Email: practicalnursing@infinitycollege.edu with any questions
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PERSONAL INFORMATION
Name
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First Name
Middle Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Telephone
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Please enter a valid phone number.
Cellular Phone:
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Please enter a valid phone number.
Email:
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example@example.com
SSN:
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D.O. B:
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Age:
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Gender
Please Select
Female
Male
Race
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Please Select
Caucasian
African American
Asian
Hispanic/Latino
Two or more races
Other
Marital Status:
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Single
Married
Separated
Divorced
Widow
Active Military:
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YES
NO
Pregnancy Status
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Yes
No
N/A
Are you registered with Selective Service?
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YES
NO
Do you give Infinity College permission to send you text and email messages?
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YES
NO
Best time to contact you:
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Morning
Afternoon
Evening
Have and of your friends or relatives attended Infinity College?
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YES
NO
If yes, please indicate who they are:
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Are you a first-time student?
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YES
NO
If no, list schools names previously attended
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Year(s) Attended:
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How did you find out about Infinity College?
Select how did you find Infinity College:
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EDUCATION
Select from listed options:
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High School
Some College
College Graduate
Year of Graduation
Last Grade Completed
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Type of Credential Earned
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Please Select
HS Diploma
GED
Did not graduate
Other
What will you do with your new credential/degree after you graduate from Infinity College?
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EMPLOYMENT
Company:
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Telephone:
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Please enter a valid phone number.
Length of Time:
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Supervisor:
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Position:
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EMERGENCY CONTACT INFORMATION
Name
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First Name
Last Name
Relationship:
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Contact Number:
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Please enter a valid phone number.
PERSONAL REFERENCES
Name
*
First Name
Last Name
Relationship:
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Telephone:
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Please enter a valid phone number.
Email
example@example.com
PERSONAL REFERENCES
Name
*
First Name
Last Name
Relationship:
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Email:
*
example@example.com
Telephone:
Please enter a valid phone number.
Back
Next
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YES
NO
Other than traffic violations, have
you ever been convicted of a
criminal offense?
Do you have any active warrants?
Do you have any unresolved arrests,
warrants or pending criminal
charges against you?
Have you ever been convicted or
pleaded guilty or no contest to
committing a felony crime?
Are you authorized to work
lawfully in the United States?
Within the past (2) two years, have
you had any communicable disease?
Do you now, or have you ever had a
substance abuse problem?
Do you have any physical or mental
disability which may affect your
studies?
Do you have any learning problems
which would affect your ability to
read or to take written tests?
Have you ever attended Infinity
College Inc. before?
Will you require any special
accommodations?
Are you currently under the
care of a physician or
psychiatrist?
Are you currently on
medication(s)?
If you answered yes to any of the questions above, please give details on a separate sheet. Physical disabilities or learning problems are not necessarily disqualifying, and these issues will be addressed and the pre-enrollment interview. Infinity College reserves the right to deny admission to applicants convicted of a sexually related offense, applicants with a communicable disease which could endanger classmates, or applicants with an untreated current substance abuse problem. If applicant has answered yes to the question pertaining to ‘conviction of a criminal offense”, applicant should submit a criminal background check and disposition of the offense(s), if applicable
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Type a question
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YES
NO
Explain "YES" answer
Visual defects/problems
Hearing defects/problems
Speech defects/problems
Cardiac disease/disorders
High Blood Pressure
Low Blood Pressure
Tuberculosis/Lung or Respiratory problems
Hepatitis or any Liver Disease
Sexually transmitted diseases
Fainting spells, epilepsy, convulsions or seizures
Diabetes
Thyroid disorders/problems
Kidney or bladder disease
Cancer
Back injuries or surgery
Joint injuries or problems
Immunosuppressive therapy
Treatment for chemical/alcohol/drug dependency
Treatment for emotional/mental health problems
Are you pregnant
COVID-19
Students with Disabilities
Students with disabilities or learning differences are encouraged to disclose and forward all supporting documentation to the school, including but not limited to IEP’s. Please send all information to Infinity College, Attn: Admission, 117 West Pinhook Rd, Lafayette, LA 70501.
Acknowledgement and Intent of Admissions
I hereby submit my application for admissions to Infinity College and affirm that all information provided in my application is best and true. I understand that by submitting by application, I intend to abide by all Infinity College policies and standards of conduct. I understand that failure to comply with the established policies and failure to comply with the tuition contract, enrollment agreement, and academic standards will result in my suspension and/or dismissal from Infinity College Inc. I understand that falsification, omission or misrepresentation of my criminal history, physical health, mental health or anything on this application may result in grounds for dismissal from Infinity College. Your signature confirms agreement and adherence with the Institution’s requirements for admissions and all policies.
Signature
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Date:
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