Application Form

Application Form

Nurse Camp Academy
Thank you for your interest in the Nurse Camp Academy!

This program is designed to support individuals aged 12–23 in exploring and beginning a rewarding career in nursing. Whether you are a middle school, high school, or college student—or already working and looking to enter the nursing profession—this program offers personal and professional development opportunities tailored to your needs. Please complete the application form below to be considered.
SECTION 1:

Personal Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact:
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
SECTION 2:

Educational Background
Current School Enrollment (Check One):*
If enrolled, please provide the following:
Name of School/Institution:*
Current Grade Level/Year:*
If not currently enrolled, please list the last school attended and graduation year:
School Name:*
Graduation Year*
Are you currently enrolled in any educational program outside of school?*

YesNo
If yes, please specify:
SECTION 3:

Work Experience
Do you have any healthcare-related experience?*

YesNo
If yes, please describe (include job title, responsibilities, and duration):
Are you currently employed?*

YesNo
If yes, Employer Name:
SECTION 4:

Program Goals
Why are you interested in the Pathway to Nursing program?*
What are your long-term career goals in the healthcare field?*
How do you plan to use this program to achieve your goals?*
SECTION 5:

Additional Information
Do you have reliable transportation to attend program sessions?*

YesNo
Are there any barriers that might prevent you from completing this program (e.g., childcare, work schedule, etc.)?*

YesNo
If yes, please explain:
Do you have any certifications (e.g., CPR, CNA)?*

YesNo
If yes, please list:
SECTION 6:

Program Commitment
Participants are expected to attend all program sessions, actively participate, and complete assignments.
Are you able to commit to the requirements of this program?*

YesNo
SECTION 7:

References
Please provide contact information for two references (personal or professional).
1. Name*

First NameLast Name
Relationship:*
Phone Number*
Please enter a valid phone number.
2. Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
SECTION 8:

Declaration
I hereby certify that the information provided on this application is true and complete to the best of my knowledge. I understand that false information may disqualify me from participation in the program.
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

Application Form

Thank you for your interest in the Nurse Camp Academy!

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Emergency Contact:

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