Admission

I would like more information about how I can jump-start my new career.

PERSONAL INFORMATION (Your information will be kept confidential and will not be released to any outside activity).

First Name:

Last Name:

Email:

Address

City:

State:

Zip Code:

Home Phone Number:

Primary Transportation:

EDUCATION HISTORY

High School Attended:

Graduation/GED Year:

Have you attended any other training or schools after High School?
If yes, which other schools or training programs have you attended?

Marital Status: Single Married.

EMPLOYMENT HISTORY

Are you presently employed?

Yes No.

If not, are you receiving unemployment?

Yes No

Are you seeking employment?

Yes No

If yes, are you seeking employment for:

Full time Part time Either

Present or last employer:

Position:

City:

State:

Dates of Employment:Â From

to

As you consider a career in the Allied Health field, what is the most important to you? Please number 1 through 6 starting with the most important.

Advancement Opportunities
Like Working with People
Position and Salary
Job Security
Benefits
Regular Hours.

What do you expect to gain by your training at Americare School of Allied Health? Check only the most important:

Career Change
Improve Education/Skills
First Job
Advancement/Improvement
Other (please explain in the space below)

Which program would you be interested in?

Medical Assistant
Nursing Assistant
Medical Office Administrator

I would like to set an appointment with an Admissions Manager so I can learn more about Americare School of Allied Health: Yes No
If yes, Date you would like to come in: Time:

Please use the space below to tell us anything about yourself that may have not been covered by the questions above.