Esthetician/Manicurist Application Form

Esthetician/Manicurist Application Form
Personal Information
Student Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Social Security Number
Ethnicity:
Driver's License
Present Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous/Current Education
School Last Attended
Year Graduated/Last Year Attended
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian's Information

ONLY FILL OUT IF YOU ARE UNDER THE AGE OF 18
Parent/Guardian's Name - Primary

First NameLast Name
Occupation
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Signature
Emergency Contact Information
In case of emergency, who will be notified? Please answer the fields below:
Emergency Contact Person

First NameLast Name
Emergency Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
File Upload

2x2 Colored ID Picture, Can be a drivers license or Passport
Driver's License

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Health History
If the student has any known allergies, please list them down below:
Does the student have any medical conditions or learning challenges that you would like to declare?
How did you hear about us?
Course of Study
Name of Course:
Mode of Study
Registration and Enrollment
Proposed Start Date

Other
Class Start: Which Date Would You Like to Enroll:
Payment Plan Option: (Pick One)
I certify that the information given on this application is true and accurate to the best of my knowledge and ability. I also acknowledge that the deposit in non-refundable once this application is submitted.

My Products

New Enrollment Deposit

This option is for individuals who are planning on being on a payment plan. This serves as the deposit for the program. When this option is selected you are registering and enrolling in our manicurist program. The deposit is non-refundable.

$500.00

Transfer Student Deposit

Students looking to transfer their hours. This is the option for you. This is a non-refundable deposit that sets up your online profile, orders your digital kit, and counts towards your overall balance.

$1,033.00 Quantity
Item subtotal:

Pay in Full

All in one Manicurist Program offering all the features to help you launch your career. This is a non-refundable deposit of $1560.

$9,500.00 Quantity
Item subtotal:

Total

Payment Methods
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty:

Esthetician/Manicurist Application Form

Personal Information

Previous/Current Education

Parent/Guardian's Information

Emergency Contact Information

File Upload

Health History

Course of Study

Registration and Enrollment

My Products