Nursing Assistant Application - East De Pere Sponsored

Date*

Name*

Last First Middle

Previous Name(s)

Mailing Address*

Number and Street City State ZIP / Postal Code Country

County*

Email*

Phone Number*

Date of Birth*

Social Security Number*

Number is used for identification purposes only.

Sex and Ethnicity

The following student data does not affect your admission status and is requested only to aid in the completion of federal, state, and college reports.

Sex*

Male
Female

Ethnicity*

Person to be notified in case of emergency:

Name:*

First Last

Email

Relationship

Phone*

Course Enrollment Information

Nursing Assistant Fall Session (August 15-October 30)*

Seeking enrollment in:

NA 150/HC 100

I am currently enrolled in high school:*

Yes
No

High School Name*

Do you currently work at a health care facility?

Yes
No

If yes, please tell us where you work.

Select each statement below to indicate that it is true and accurate

Select (check) each box:*

The information I have provided is correct in all aspects.
I understand that this registration does not imply current or future admission to any Bellin College degree program option. If I wish to apply for admission into one of the programs of study, I must complete a Bellin College Undergraduate application.
I agree to comply with all applicable rules/regulations and policies articulated in the Bellin College – Nursing Assistant Program, Parent/Student Handbook in effect during the enrollment term of my registration.
I understand that the courses taken will be granted college credit at Bellin College and may transfer to another institution only at its discretion, according to its transfer rules.
I understand that completion of this credit will result in the creation of a permanent enrollment record at Bellin College.
I confirm that college policy regarding the Family Educational Rights and Privacy Act (FERPA) and access to my student record was explained to me.
I agree that I am liable for all fees related to this enrollment. I agree to all conditions outlined in the Bellin College Tuition & Fee Schedule.
I understand that enrollment requires payment in full by the first day of class. Payment is refundable if I withdraw prior to first class meeting.
I understand that this State of WI directed program requires attendance at every class. I have no conflicts with my personal schedule that would interfere with this attendance requirement. I understand that Bellin College is not able to offer special requests for missed classes. The make-up dates listed on the course calendar are only for extenuating circumstances associated with illness, emergencies, or weather.

Signature

Sign by printing your name in the box below.*