Student Enrollment Form

Student Enrollment Form

3516 NW 50th St, Oklahoma City, OK 73112 Phone: 405-964-1714
Student Information
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Email
example@example.com
Date of Birth

MonthDayYear
Date
Place of Birth (County, State)
Do you have any special needs? (Please List)
Ethnicity

Hispanic/LatinoAmerican Indian/ Alaska NativeAfrican AmericanAsianWhite/CaucasianNative Hawaiian/ Pacific IslanderMiddle EasternOther
Education
Which program are you enrolling for?*

Basic CosmetologyBarberingCosmetology CrossoverBarber CrossoverMaster InstructorReview Hours
Do you have a High School Diploma / GED?

YesNo
Name of High School
Address of High School

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of School
Highest Level of Education:

Some High SchoolHigh School Diploma / GEDTrade School/Vocational TrainingAssociates DegreeBachelors DegreeMasters Degree
Name of Trade / Vocational School
Address of Trade / Vocational School

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beginning Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Field of Study
Name of College Attended
Address of College attended

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beginning Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Field of Study
Name of Any Other School Attended
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beginning Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Field of Study
Do you have any previous training or licenses that pertain to Cosmetology or Barbering? If so, list below:
Name of Cosmo/Barber School Attended
Address of Cosmo/Barber School Attended

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beginning Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Name used while enrolled
What other skill sets do you have? (Communication skills Teamwork Office Skills Computer Skills etc.)
For Justice Involved Individuals
Do you have any current or pending charges?

YesNo
If yes please charges below (try to include case #'s)
Name of County, State you were charged in:
County
State
If more room is needed to list charges, please enter below:
Are you currently on Probation or Parole?

YesNo
Name of Probation/Parole Officer
Phone Number of Officer
Are you participating in any rehabilitation programs? if so list below:
Reference Info
Personal Reference #1

First NameLast Name
Phone Number
Email Address
example@example.com
Personal Reference #2

First NameLast Name
Phone Number
Email Address
example@example.com
Personal Reference #3

First NameLast Name
Phone Number
Email Address
example@example.com
Goals and Ambitions

Why do you want to participate in the RISE Cosmetology/Barbering program?

What are two goals you hope to achieve by completing this program?
Goal 1*
Goal 2*
Is there anything you would like us to know about you
By signing below, you are agreeing that the information provided above is true and correct, to the best of your knowledge.
Signature*

Clear
Date

MonthDayYear
Date
Name

First NameLast Name
Should be Empty: