September Program Enrollment Form
Student Name
*
Student First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
SSN
*
Driver's License Number
*
Emergency Contact name
*
Emergency Contact phone number
*
Name of School
*
Year Graduated
*
Specify Degree or Diploma
*
Work Experience
1. Employer Name
*
Employer Phone
*
Employer Address
*
Manager's Name
*
Specify Dates Employed
*
Reason for leaving
2. Employer
Employer Phone
Employer Address
Specify Dates Employed
Manager's Name
3. Employer
Employer phone
Employer Address
Specify Dates Employed
Manager's Name
Reason for leaving
References
Reference Name
*
Phone
*
Relationship
*
Reference Name
*
Phone
*
Relationship
*
Preferred Program (Applicable tuition assistance or Out of Pocket Discounts and Payment Plans available)
*
Day (In-Person ) Tuition $1500
Hybrid (Day hours) Tuition $1500
Scrub Size
*
Please Select
XS
S
M
L
XL
2XL
3XL
4XL
Please tell us why you are interested in this program
*
Please Upload Driver's license or State ID and Copy of Covid vaccine Record
*
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I attest that all information disclosed is correct. I authorize Nursing EDification to use pertinent information provided on this form to determine eligibility for enrollment and I acknowledge the required application fee is non- refundable after 3 business days.
Signature
*
My Products
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Application Fee
non- refundable after 3 business days or once background screening is completed
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Evening or Weekend Intial Deposit
Deposit will be deducted from total tuiton costs
$
350.00
Product Name
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
How did you hear about our program?
*
Friend/ Family
Social media
Flyer/business card
Other
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