First Name

Last Name

Home Address

Country

Address Line 1

Address Line 2

City

Province

County

Zip / Postal Code

Email Address

May We Text You? May We Text You? Yes No

Citizenship Status Citizenship StatusUS CitizenPermanent ResidentEligible Non-CitizenRefugee Status

Current Employment - Company Name

Position

Status StatusFull timePart timeNot applicable

Average Weekly Hours

Supervisor's Phone

Education Have you attended any other PN nursing programs? Education Have you attended any other PN nursing programs? Yes No

What Program are you interested in? What Program are you interested in?Practical Nursing Program (Day)Practical Nursing Program (Evening)AAS Nursing

What Term do you want to begin? What Term do you want to begin?September 2026September 2027May 2026May 2027January 2027

Please select if you are currently a: Please select if you are currently a: CNA GNA Medical Assitant

Please select all degrees you have earned in the United States: Please select all degrees you have earned in the United States: High School Diploma GED Associates Degree Bachelors Degree Masters Degree

Do you have a student loan? Do you have a student loan? Yes No

Are you currently in federal student loan default? Are you currently in federal student loan default? Yes No

Do you have a criminal record? Do you have a criminal record? Yes No

Do you need any accommodations while in the program? Do you need any accommodations while in the program? Yes No

Have you Received Flu Vaccine? Have you Received Flu Vaccine? Yes No

Have you received COVID19 Vaccines? Have you received COVID19 Vaccines? Yes No

Please select desired program duration: Please select desired program duration: Day Program: 16 Months for PN Program (8am-4pm) Evening Program: 16 Months for PN Program (4:30pm-9:30pm) Day Program: 16-24 Months for RN Program (Duration Dependent on Prerequisites and LPN)

Student Signature