Student Registration Form

The Pulse Academy

931 N Greer Blvd Pittsburg, Tx 75686

www.thepulseacademy.org

903-708-7101
Student Application

Please allow 24-48 hours for a response thank you!
Access to The Pulse Academy's programs or activities shall not be limited on the basisi of race, color, creed, national origin, religion, age, gender, sexual orientation, political affiliation, or physical disability.
Name*

First NameLast Name
Email
example@example.com
Gender
Phone Number
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Date Of Birth*

MonthDayYear
Date
Social Security#*
Emergency Contact
Please enter a valid phone number.
Are You A Us Citizen

YesNo
Highest Level of Education Completed ( middle school, high school, associates degree, bachelor’s degree, some college)*
Are you CPR certified through The American Heart Association?*

YesNo
Courses Pick One*

Nurse AideMedication AidePhlebotomyMedical AssistantPharmacy TechnicianSterile Processing TechnicianEstheticianNail TechnicianLash TechnicianIV Certification
Have you ever been convicted of a Felony? If yes please explain, if ‘’NO’ write N/A in the box*
Why are you interested in your chosen field of study?*
What are your hobbies and interests?*
Is there any reason you should not be able to complete this course (If yes please explain)*
Do you have any unique needs, learning disabilities, health concerns, etc. that would require adapting this program to meet those needs?*
Is there anything you would like to share with us about yourself?*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact 1
Name*
Phone*
Relationship*
Email*
Emergency Contact 2
Name*
Phone*
Relationship*
Email*
Employment
Place Of Employment*
Date Of Hire*

MonthDayYear
Date
Type Of Facility *
Job Title*
Type Of Work Performed*
Front of State Issued ID

Cancelof
Back of State Issued ID

Cancelof
I hereby certify that the information contained in the application is true and complete to the best of my knowledge. I understand that any misrepresentation or falsification of information is cause for denial of admission or expulsion from The Pulse Academy. I understand that the faculty and staff of The Pulse Academy will read the information contained in the application.

I have read and understand all the information included as part of this application.

*When a student applies to the school they are giving permission for the school to conduct a criminal history check*
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date

Application Fee

$55.00

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Should be Empty:

Student Application

Emergency Contact 1

Emergency Contact 2

Employment

Payment Methods