PERSONAL INFORMATION

First Name:*

Middle Name:*

Last Name:*

Maiden or Other Name (if applicable)

Marital Status*

Address:*

City:*

State:*

ZipCode:*

Home Phone:

Mobile:*

E-Mail:*

**REQUIRED to provide support for financial, IRS, other government services, and financial aid

SSN**

Birth Date:*

Gender

Facebook ID:

Emergency Contact First Name:*

Emergency Contact Last Name:

Emergency Contact: Relationship*

Emergency Contact Phone #:*

Have you ever been convicted of a crime:*

If yes: convicted of a crime : Please Describe

Please select the group, which most closely represents you*

Please select one of the following groups, which most closely represents you*

Group Other:(Please specify)

IMPORTANT ADMISSIONS INFORMATION

I plan to enroll:

Academic Program you plan to pursue:*

Immigrant Status*

If Permanent Resident: (Alien #)

If Other Status Type: (Please specify)

Is English your second or third language?*

If Yes, indicate your first language:

Are you a veteran?*

Do you plan to apply for financial assistance?*

EDUCATIONAL hISTORY

Name Of High School*

High School City/State:*

High School dates of attendance (MM/YYYY - MM/YYYY)*

Higest HS Grade completed*

Do you have a High School Diploma or GED?*

Diploma Received?*

What year did you graduate High School or obtain your GED?

Have you previously attended College / University?

Highest Level of Education*

Please list all Colleges / Universities previously attended:

Institution 1: Name

Institution 1: City/State

Institution 1: Dates of Attendance (MM/YYYY - MM/YYYY)

Institution 1: Degree(s) Received

Institution 2: Name

Institution 2: City/State

Institution 2: Dates of Attendance (MM/YYYY - MM/YYYY)

Institution 2: Degree(s) Received

STUDENTS APPLYING TO THE PRACTICAL NURSE PROGRAM

Eligibility to Sit for NCLEX-PN:Upon successful completion of all Abcott Institute Practical Nurse Program requirements, a graduate will earn a Certificate of Completion and is eligible to apply to take the National Council Licensure Examination for Practical Nurses (NCLEX-PN®). To become licensed in Michigan, an applicant must apply for a license with the Department of Licensing and Regulatory Affairs (LARA) who will determine eligibility to take the exam. Passing the NCLEX-PN results in licensure as a Practical Nurse. Background Check: A fingerprint report and criminal background check are required for application to take the exam. Fingerprints must be taken using the instructions and ID numbers that are sent to the applicant after the license application and fee are received. Adverse events on the criminal background check may hinder an applicant’s application and eligibility to take the exam. Students may address any questions or concerns about licensing and eligibility to LARA at www.michigan.gov/healthlicense.

FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA)

This law protects a student’s right to the privacy of their educational records. Abcott Institute will not release student directory information without the written permission of that student. However, the student may authorize the release of this information on this application by initialling the appropriate place below. The college includes the following information in its directory file on students:

Name Home Address * Telephone Number
* Place of Birth * Program of Study
* Dates of Attendance
* Degrees, Certificates, and Awards Received
* Most Recent Education Institution Attended
* E-mail address

I request that Abcott Institute not release my directory information without my express written permission. I understand that requests from potential employers and others seeking to verify my attendance will not be answered unless I have given that requestor a signed release to give the Institute.

Request:

Do not release my directory information without my express written permission.

I authorize Abcott Institute to provide my directory information to requestors in accordance with the limitations placed upon them by FERPA.

Authorization

I authorize Abcott to provide my directory information to requestors..

I authorize Abcott to check my records on NSLDS to check status of my loans.

I certify that all entries on this application are complete and accurate to the best of my knowledge. I understand that falsifying any information on this application could result in dismissal from the Institute.

I certify:

I certify....

By checking this box, I give consent for Abcott Institute to use automated technology to call and/or text me at the number provided above, including my wireless number if applicable. Message and data rates may apply. Text STOP to opt out or HELP for help.