Registration Form

Please complete form and submit your payment. Note that there is a $3.00 convenience fee applied to the registration cost. Please allow 24-48 hours for processing (excluding weekends/holidays)

Date of Application

Address Program Program Start Date

Personal Information

First Name Last Name Date of Birth (Must be 18+)

City State Zip Code Cell Phone Please text me with information regarding the courses offered. MSG and data rates may apply. I can text Stop at anytime to end.

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

Email Address

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?

Educational Experience

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

Criminal Background Information

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

Do you have a misdemeanor? Yes No

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

Were you convicted?

Fees

Registration Fee (Non-refundable deposit) Class Materials

Please upload a copy of your state issued ID.

Personal Information

Health Background

Educational Experience

Criminal Background Information

Fees

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