HEALTH-TECH

Name

First NameMiddle NameLast Name

Date of Birth:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County

Email

example@example.com

Phone Number

Applicant’s Status:

Intended Major:

Term of Admission: (select one)

Day or Evening Classes:

Are you a U.S. Citizen? Yes or No?

Native Language Visa Type Expiration Date Note: A copy of Permanent Resident Card or I-94 must be on file prior to registration. Please put N/A in box if prospective student does not have a Visa.

Month

Day

Year

High School or GED Education: (complete each section)

High School or GED Institution Name:

Date of Graduation or Completion:

Are you currently working? If so, are you grossing less than $600.00 per week?

Are you receiving SNAP (Food Stamps) benefits?

Do you have any accommodations you may need while in training? If so please explain?

If so please explain?

College/University Education: Please provide previous College/University information at initial interview.

Hepatitis B Immunization Health History mandated by the State of Tennessee

Hepatitis B (HBV) is a serious viral infection of the liver that can lead to chronic liver disease, cirrhosis, liver cancer. liver failure, and even death. The disease is transmitted by blood and/or body fluids and many people will have no symptoms when they develop the disease. The primary risk factors for Hepatitis B are sexual activity and injected drug use. The disease is completely preventable. Hepatitis B vaccine is available to allage groups to prevent Hepatitis B viral infection. A series of three (3) doses of vaccine are required for optimal protection. Missed doses may still be sought to complete the series if only one or two have been acquired. The HBV vaccine has a record of safety and is believed to confer lifelong immunity in most cases.

I hereby certify that have read this information and I have received the complete three dose series of the Hepatitis B vaccine.

Date of Completion of the Hepatitis B vaccination series

Thereby certify that I have read this information and I have elected NOT to receive the Hepatitis B vaccine.

Check box

Date

For more information about the Hepatitis B disease and its vaccine, please contact your local health care provider or consult the Center for Disease Control and Prevention Web site at Iwww.ede.gov/health/defaulthtm]

Draft Registration All male citizens of the United States of America, born in 1960 or after, must have registered for the draft prior to registering for classes. This requirement does not apply to veterans and others exempt by federal laws. Yes Have you registered for the draft?NoExempt

I have read and understand the statements provided on the instruction page and I agree that Health-Tech Institute of Memphis may release information from my file according to the Buckley or Solomon Amendment: and certify that all information on this form is true and that no information has been withheld. I understand that withholding information or giving false information may make me ineligible for admission or subject to dismissal. With this in mind, I certify that statements provided are correct and complete.

Health-Tech Institute of Memphis, an authorized Tennessee Higher Education Commission institution, is an equal opportunity school 20100813

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HEALTH-TECH INSTITUTE OF MEMPHIS

APPLICATION FOR ADMISSION

HBV TO BE COMPLETED BY ALL STUDENTS