NCI Enrollment Documents

Enrollment Documents

Complete all the documents after completing the Enrollment Agreement.
Hepatitis B Vaccine Request or Declination Form
I understand that due to my occupational exposure to blood or other potentially infectious materials (OPIM), I may be at risk of acquiring hepatitis B virus (HBV) infection.

I understand that vaccination is my responsibility or declination is required.
Please select one of the following:
Name

First NameLast Name
Signature

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Date

MonthDayYear
Date

Background Check Authorization Form
Name

First NameLast Name
Maiden Names or Aliases used in the past 5 years: *

First NameLast Name
First NameLast Name
Social Security Number
Date of Birth
Have you ever been convicted of a misdemeanor or felony:
Are you waiting prosecution of a misdeameanor or felony?
Have you pled nolo contendere (no contest) to a misdeameanor or felony?
If yes, give details including charges, city, county and state where occurred and year:
Please read the following carefully before signing this authorization form.

I understand that as part of the procedure for processing my application, an investigation report about my background may be made which may include information obtained through personal interviews, regarding my character, general reputation, personal characteristics, or mode of living. I have the right to make a written request, within a reasonable period of time, for complete disclosure of additional information concerning the nature and scope of the investigation. I authorize investigation of all statements contained in this authorization form. All representation by me in this data sheet an adverse nature. Inaccurate information may make me ineligible for enrollment. I also understand that having a criminal conviction is not an automatic bar for enrollment.
Signature

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Photo and Video Consent
I hereby grant permission to Nursing Careers Institute Inc. (NCI) to use photographs and/or videos of me taken during my term as a student of NCI and any location in association with NCI. These photos may be used for publications, news releases, social media, and in other communications related to the mission of Nursing Careers Institute Inc.
Name

First NameLast Name
Signature

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Date

MonthDayYear
Date
Photo

Please upload a photo/selfie of yourself with a white background that will be used to create your badge. Only a headshot is necessary.
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Documents

Please upload all documents prior to the first day of class. Two forms of ID will be required in which you will bring to class. Acceptable forms of ID include: (1)Social Security card (or), Employment Authorization Document (DACA)(or) Birth Certificate; (2)Valid Driver's License (or) DMV ID Card (or) Military ID
Transcript

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Physical Assessment

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TB Skin Test

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Immunizations

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Should be Empty:

Enrollment Documents