Nursing Careers Institute Admission Application

Admission Application

Application is not complete until registration fee is paid.
Prospective students must be 17 years or older before graduation or completion of the Nurse Aide program and must show proof of the following:
- Submit a completed admission application and enrollment agreement.
- High School, GED or College Transcript (showing High School completion or college graduate)
- High School students must complete a basic skills test.
- Registration fee (Refundable before the first day of class)
- Government issued ID with picture and signature
- One of the following: Social Security Card, Employment Authorization Document (DACA) or Birth Certificate
- Criminal Background (completed by Nursing Careers Institute)
- Physical Examination (provide copy of last exam; must be within a year)
- TB skin test (mandatory prior to clinical rotation)
- Copy of any immunizations; Hepatitis B is required or a declination form is acceptable.
What program?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB
Last 4 digits of Social Security Number
Must bring physical copy of card on the first day of class.
Home Phone #
Format: (000) 000-0000.
Cell
Email Address
example@example.com
Start Date

MonthDayYear
List the class date you would like to attend.
End Date

MonthDayYear
Date
HIGH SCHOOL NAME
START DATE
END DATE

MonthDayYear
Date
Are you still in high school?*
Note: High School students are required to take a basic skills test. Once accepted into the program, a link will be provided to you to complete the test.
Are you a high school graduate? (Transcript required after acceptance)*
Diploma or GED*
Other Education
Other Certifications
Uniform Size

TERMS AND UNDERSTANDING
Fees and Charges:
- $75.00 Registration Fee
- $699.00 Tuition (Nurse Aide I)
- $350.00 Tuition (Nurse Aide I Refresher)
- $325.00 Tuition (Medication Aide/Tech)
- $50 CPR (Provided during skills week if needed)
Other out of pocket fees: TB Test (Can be done at primary care physician or local pharmacy clinic).
Student Acknowledgment and Agreement

I understand and agree to the following:

Nursing Careers Institute does not guarantee employment following program completion. Employment opportunities may exist, however, students must meet the hiring requirements of the employer.

The school reserves the right to terminate a student’s enrollment for reasons including, but not limited to:
- Failure to follow the Attendance Policy
- Failure to maintain satisfactory academic progress
- Failure to follow school rules and regulations
- Nonpayment of tuition or fees
- Other reasons outlined in the school catalog
Tuition and fees must be paid according to the published tuition payment schedule. Students who have not met their financial obligations may be restricted from participating in clinical training or completing the program.

Materials used in the classroom, skills laboratory, and instructional settings are the property of Nursing Careers Institute and may not be removed without authorization.

The school does not guarantee the transferability of credits or training hours to any other educational institution. Decisions regarding transfer of credit are made solely by the receiving institution.

Notification of withdrawal or cancellation must be submitted in writing to the school administration.

Student Right to Cancel

Students may cancel their enrollment agreement at any time prior to the first day of class and receive a 100% refund of tuition and fees paid, in accordance with the school’s refund policy.

To cancel the enrollment agreement, students must provide written notification to the school administrator by email or written communication.

Acknowledgment

My signature certifies that I have read, understood, and agreed to my rights and responsibilities, that the institution’s cancellation and refund policies have been explained to me, and that I have received a copy of this agreement.

I hereby accept this agreement with Nursing Careers Institute, Inc.
Student Signature

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Date

MonthDayYear
Date

Student Interview Form for

NC Nurse Aide I and Nurse Aide Refresher Program
Complete all questions:
1. What do you think it takes to be a good Nurse Aide?
2. What are three 3 words your friends would use to describe you?
3. Give an example of a time when you had to learn something new i.e. a task or procedure. How did you learn the new task or procedure?
4. Describe your best learning experience. What made the experience a good one?
5. Where do you see yourself in 3-5 years?

Emergency Notification Information
Emergency Contact #1
Relationship to the Applicant
Contact
Emergency Contact #2
Relationship to the Applicant
Contact
Hospital Preference
Primary Care Physician
Known Allergies
Previous Medical Conditions
*This information is for information purposes ONLY in case of an emergency. This information will not be used to determine admittance of an applicant.

Fee:

Registration Fee

Registration fee is 100% refundable before the first day of the program.

$75.00

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

Afterpay

Should be Empty: