About Community Helpers Healthcare Career Centers

Student Name: _____________________   Date of Birth: ___________________ Gender: ____

Email: _____________________________Phone: __________________Cell phone: ________

Street Address: _____________________ City: _________________ State: _____ Zip: _______

SSN #: __________________________Race: ________________ Marital Status: ___________

Driver’s License # _____________________________ Year of Graduation: _________________

Last Grade Completed: ___________________________

PROGRAM OF INTEREST: ___________________________________________________

Please circle the correct answer:

Other than traffic violations, Have you ever been convicted of a criminal offense?  YES  OR  NO

Are you authorized to work lawfully in the United States?             YES      OR       NO

Do you now, or have you ever had a substance abuse problem? YES      OR       NO

Will you require any special accommodations?    YES      OR       NO

If you answered yes to any of the questions above, please give details bellow:

___________________________________________________________________________

Acknowledgment and Intent of Admissions I hereby submit my application for admission to the Community Helpers Healthcare Career Center and affirm that all information provided in my application is best and true.

Student Signature: ________________________            Date: ________________