Student Application
Address: 1909 Q Street NW, Suite 300 Washington DC 20009
Web: www.stjosephsmed.org
Phone: 202-539-2333
Student Name
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Last Name
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What is your preferred name?
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How did you hear about us?
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What is your date of birth?
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Are you at least 18 years old or older?
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yes
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What is your email address?
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Are you a previous student of St. Joseph's?
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yes
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Gender
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What are your pronouns?
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Address
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Street Address
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City
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Mobile Number
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Work Number
Social Security Number
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Emergency Contact Name
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First Name
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Emergency Contact Number
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Relationship?
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Spouse
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Other
Do have any medical or food allergies? If so, please list.
Ethnicity (Race/Ethnicity information will not be used in a discriminatory manner.
Hispanic or Latino
Asian
Black or African American
White
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
Other
Prefer Not to Answer
Do you consent to a Criminal Background Check (CBC)?
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Yes
No
Do you consent to a Drug Screen?
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Yes
No
Uniform Scrub Size
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X=Small
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4XL
5XL
Will you need a payment plan?
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Student Acknowledgement
I understand that the school may terminate my enrollment if I fail to comply with attendance, academic, and financial requirements or if I fail to abide by established standards of conduct of SJMCTS. While enrolled in the school, I understand that I must maintain satisfactory academic progress as described in the school catalog and that my financial obligation to the school must be paid in full before a certificate may be awarded.
*
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Agree
Disagree
I understand that the school does not guarantee job placement to graduates upon program completion or upon graduation
*
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Agree
Disagree
I understand that complaints, which cannot be resolved by direct negotiation with the school in accordance to its written grievance policy, may be filed with the Higher Education Learning Commission for the District of Columbia.
*
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Agree
Disagree
As a SJMCTS student, I understand the Academic Integrity principles. I agree to maintain the highest standards of personal integrity and academic honesty in all endeavors. I understand that any violation of these principles will result in termination from my current program.
*
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Agree
Disagree
Read and Sign SJMCTS Release and Waiver of Liability
Signature
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SJMCTS RELEASE FORM FOR MEDIA RECORDING
I, the undersigned, do hereby consent and agree that SJMCTS, its employees, or agents have the rights to take photographs, videotape, or digital recordings of me and to use these in any and all media, now or hereafter known, and exclusively for the purpose of pictures. I further consent that my name and identity may be revealed therein or by descriptive text or commentary. I do hereby release to SJMCTS, its agents, and employees all rights to exhibit this work in print and electronic form publicity or privately and to market and sell copies. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used. I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback. I also understand that SJMCTS is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sickness or injury incurred as a result. I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.
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First Name
Last Name
Signature
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PRIVACY POLICY
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Application Fee
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75.00
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