Pure Institute of Electrology

Pure Institute of Electrology

Application For Enrollment
Pure Institute of Electrology
Student Information
Name

First NameLast Name
M.I.
Birth Date

MonthDayYear
Social Security Number
Gender
Email Address
YesNo
If yes, what year?
Current Residence Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years/Months at Current Residence
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Primary Residence Information (if different from above)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact
Name

First NameLast Name
Phone Number

Area CodePhone Number
Physician and Medical Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Preferred Hospital
Insurance/Health Coverage (Company)
Insurance Company Policy and Phone Number
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.

Last School Attended
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
YesNo
High School Attended (if different from above)
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Date
YesNo
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
Government Issued Identification

Cancelof

Application Fee

Application Fee

Non-refundable Application Fee

$25.00

Total

$0.00

Credit Card

Should be Empty: