Application

Campus Preference:*
Program:*
Desired Start Date*

Contact Information

Legal First Name:*
Legal Last Name:*
Preferred Name:
Social Security Number:*
Legal Gender*
Gender Preferred:
Pronouns Preferred:
Birth Date:
Mobile:*
Email Address:*

Personal Information

Ethnicity*
If other: Please specify:
Citizenship*
If not a US Citizen - Visa Number:
Place of Birth:*

Additional Information

Marital Status:*
How do you plan on paying for school?*
Do you have a GED?*
Are you a dependent?*
Do you have any dependents?*
Do you have GI Bill Benefits?*
ADA Accommodations:
Do you have Transfer Hours?*
Dominant Hand:*

Primary Address

Country:*
State:*
Zipcode:*
City:*
Address:*

Emergency Contact Information

Emergency Contact Full Name*
Emergency Contact: Relationship*
Emergency Contact: Cell Phone Carrier
Emergency Contact: Email*
Emergency Contact: Cell Phone Number*

References

Reference 1: Full Name*
Reference 1: Relationship*
Reference 1: Phone*
Reference 1: Email*
Reference 2: Full Name
Reference 2: Relationship
Reference 2: Phone
Reference 2: Email
Reference 3: Full Name
Reference 3: Relationship
Reference 3: Phone
Reference 3: Email
By submitting this form, I agree that Cinta Aveda Insitute may call, text and/or email me about their educational services at the contact information provided, including a wireless number, using automated technology. Please note, I understand that this consent is not required to attend the Cinta Aveda Institute and I may withdraw my consent to such contact.