Program Application Form 2024

Program Application Form
Please select the desired program:*

Nurse AidePhlebotomyIn-PersonHybrid ( online and in person)Clinical rotation -Nurse Aide Only(speak to school rep prior to application)
Class Start Date

MonthDayYear
Applicant Application
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Social Security Number or Alien Number*
Are you a citizen of the United States?*
If no, are you authorized to work in the US?*
Have you ever applied to this school before?*

YesNo
If yes, when
Have you ever been arrested or convicted of a felony?*

YesNo
If yes, please explain
How did you find us?*
Education
Highest level of education*

High SchoolAssociatesBachelorsMasters
Highschool/ College*
City and State/ Country
Did you graduate?*
What are your career goals?*
Health History
Allergies*

YesNo
Description
Medications*

YesNo
Description
Heart problems/conditions*

YesNo
Description
Lung issues(asthma, COPD)*

YesNo
Description
Smoker*

YesNo
Description
Hearing problems*

YesNo
Description
Back problems*

YesNo
Description
Knee problems*

YesNo
Description
Recent surgeries*

YesNo
Description
Lifting Restrictions*

YesNo
Description
Mental Health*

YesNo
Description
Anxiety*

YesNo
Description
If you are pregnant, have any back problems/ lifting restrictions, or any medical condition that is being monitored by a physician; a note is required from such physician stating that you are in good health. The note should also include that you are free of any communicable disease and have no known deficits that will interfere or prevent you from fully participating in class, skills lab and clinical rotations. All three of the previous components are required for completion of the Nurse Aide program.
Please list any other medical conditions that you may have that are not mentioned above, that you feel may present as a risk or obstacle for you; or that you feel your instructor should be made aware of to protect your well-being and safety:
Please share any other medical conditions not listed
Emergency Contact Information
In case of emergency, who will be notified? Please answer the fields below:
Emergency Contact- Primary*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Emergency Contact - Secondary

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Payment
Confirmation & Signature

Typing your full name below certifies your consent and agreement
Student Signature*

Clear
Date Signed*

MonthDayYear

Registration Fee- $100.00*

USDYour registration fee must be received in order to process your application form. Please ensure you have spoken with a school representative, PRIOR to course registration. **THIS registration FEE IS NON-REFUNDABLE**Description

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

Afterpay

I certify that my answers on this application are true and complete to the best of my knowledge. If accepted into Diamond Career Institute, I understand that any false or misleading information contained in my application or interview, regardless of the time of discovery, may result in my dismissal from the program. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent to references or educational institutions listed, being contacted.
Should be Empty:

Program Application Form

Applicant Application

Education

Health History

Emergency Contact Information

Payment

Confirmation & Signature

Payment Methods