Registration Form

Please complete form and submit your payment. Registration fee is non-refundable. Individual must be 18+ in order to register for any course.

Date of Application

Program Program Start Date

Personal Information

First Name Last Name Date of Birth

Address City State Zip Code Cell Phone

Sex Male Female Trans Female (male to female) Trans Male (female to male)

Email Address

Educational Experience

Highest Level of School Completed Did you graduate from high school? Did you graduate from college? Who is your current employer? If applicable, what is their phone number? Emergency Contact Information (Please include name, relationship, phone number, and address)

Criminal Background Information

Have you ever been arrested? If yes, why? Were you convicted?

Do you have a misdemeanor? Yes No

Do you have a felony? *Please note that felons will be rejected* Yes No

Have you ever been expunged or pardoned of a crime? If yes, please further explain.

Health Background

Are you on any medications? If yes, what are they? Do you have a medical diagnosis? If yes, what is your diagnosis? Would your diagnosis affect your performance in the program? If so, in what manner? Registration Fee

Personal Information

Educational Experience

Criminal Background Information

Health Background

Submitting this form, I declare that the information contained in this application is true and complete. If information is false, I will be expelled.