Cosmetology Beauty School Enrollment & Admission

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ENROLLMENT APPLICATION


School Location:	Code:

Personal Data

*First Name:

*Last Name:

MI:

*Street address:

*City:

*State:

*Zip:

*Phone:

*e-mail:

*SSN:

*Date of birth:

*Sex: Female Male

*Citizenship: US Alien No. A-

Other

*Do you require any help or assistance to help you successfully complete the program? If so, please indicate:
(If not applicable, enter N/A)

*Veteran (US): Yes No

*Marital status: Single Married Separated Divorced Widowed

Number of Children:

*Housing during enrollment:

With parents

Own place (Renting/Buying)

*Ethnic Group This information is required for statistical reporting to IPEDS, a contractor of the USDE.

Educational Data

For items not applicable, enter N/A

Diplomas, Certificates or Degrees earned that are equivalent and recognized by the United States educational system

HIGH SCHOOL: (please read carefully)

Check this box ONLY if you have completed U.S. High School or its equivalent

If you have not completed High School or its equivalent, provide last U.S. equivalent grade completed

*Last High School:

Dates Attended :

*Do you have a bachelor degree or above from a college or university?	YesNo
*If yes, what is your graduation date:

Financial Aid History: Check this box ONLY if you have applied and/or received financial aid

Employment Experience

*Current or last employment:		*Position Held:
*Dates of Employment: To	*Rate of Pay:	*(check one) Hr Wk Mo.

*Street address:

*City:

*State:

*Zip:

*Phone #:

*Leaving Reason:

Family Data and Emergency Contact

	Father’s	Mother’s	Contact person in an emergency
*Name
*Address
*City/St/Zip
*Phone

Personal Reference (You must provide complete references that are NOT family members)

	Reference 1	Reference 2	Reference 3
*Name
*Address
*City/St/Zip
*Phone

*How did you hear about our school?

*What course of study are you interested in?

*Males: Registered with Selective Service? Yes No		*Females: Pregnant? Yes No
*Have you ever been convicted of a misdemeanor or felony? YesNo
*Receive updates, special coupons, and beauty tips by E-mail: YesNo

By checking this box, I certify that all information on this form is true and correct to the best of my knowledge. I also understand that I may be required to provide supporting documentation of the information reported. And, by signing my name in the "Applicant's Signature" box, I confirm that I agree to the terms and regulations of this application.