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First name :

Middle Name :

Last name :

Maiden Name :

Complete address. :

Preferred location to attend Clinical First Preference - - Bowling Green Brandenburg, KY LaGrange, KY Lexington Louisville, KY Owensboro, KY Not Preferred Second Preference - - Bowling Green Brandenburg, KY LaGrange, KY Lexington Louisville, KY Owensboro, KY Not Preferred Third Preference - - Bowling Green Brandenburg, KY LaGrange, KY Lexington Louisville, KY Owensboro, KY Not Preferred Fourth Preference - - Bowling Green Brandenburg, KY LaGrange, KY Lexington Louisville, KY Owensboro, KY Not Preferred

Complete date of birth : - - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - - Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - - 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 2051 2052 2053 2054 2055 2056 2057 2058 2059 2060 2061 2062 2063 2064 2065 2066 2067 2068 2069 2070 2071 2072 2073 2074 2075 2076 2077 2078 2079 2080 2081 2082 2083 2084 2085 2086 2087 2088 2089 2090 2091 2092 2093 2094 2095 2096 2097 2098 2099 2100

Phone number :

Social security number (No Spaces, eg : xxxxxxxxx) :

Have you ever been convicted of a felony? If so explain. : Yes No

Have you ever been found guilty of abuse? If so, explain. : Yes No

Do you have any learning disabilities that may need accommodation? If so, explain. : Yes No

Are you taking this course for a nursing school pre-requisite? If so, which school?

Do you have a deadline to complete this course for your Nursing School? If so, please share your school and deadline date information here. : Yes No

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There is no refund on any tuition,insurance,or textbook charges... Please refer to the school catalog for all policies and fees...

I have read and understand the school catalog

I give permission to Health Education Center to email my TB Tests and Background check to the HEC approved Clinical facility I will attend.

I agree to email or fax my TWO STEP TB Test or TB Blood test results and Background check to HEC at least 3 days before my Clinical date to attend.