New Nursing Enrollment Application

Hearts Associates Institute

1054 Gateway Blvd - Suite 110, Boynton Beach, FL 33426

Nursing Enrollment Application

Last Name

First Name

Middle Name

Street

City

State/Province

Zip/Postcode

County

Home Phone

Cell Phone

Work Phone

Gender

Date of Birth

Are you at least 18 years of age?

Yes No Not Selected

Name of Parent/Guardian

(If applicant is under 18)

Social Security No

High School Graduate?

Yes No Not Selected

Program

A minimum of a high school diploma (or equivalent) is required. List it below:

High School's Name

State

Dates Attended

List institutions attended prior to HAI: (This information must be provided for transfer credits if applicable)

Institution's Name

State

Dates Attended

Degree Awarded

Institution's Name

State

Dates Attended

Degree Awarded

Institution's Name

State

Dates Attended

Degree Awarded

Background Check

Have You Ever Been Convicted of a Felony?

Yes No Not Selected

If Yes, Please Explain

Emergency Contact

Contact Name

Relationship

Cell Phone

Is Their Mailing Address the Same As Yours?

Yes No Not Selected

Contact Address

Contact City

Contact State

Contact Zip Code

Contact County

Citizenship

List Nation of Citizenship. Non-U.S. Citizens only: Resident Alien#: Complete Visa Information, (COPY OF RESIDENT ALIEN CARD OR VISA TYPE MUST BE SUBMITTED WITH YOUR APPLICATION: MUST BE VALID THROUGH TERM OF ENTRY)

Country

Visa Type

Visa Issue Date

Visa Exp. Date

What is your Ethnicity?

Hispanic or Latino/Latina

Hispanic/Latino (Latina)

Non-Hispanic/Latino (Latina)

What is Your Race?

Check One or More That Apply.

Prior Education Standing

I am in good standing at the last institution attended (eligible to enroll). If "No," you are not eligible to attend HAI.

Yes No Not Selected

If your answer to either of the following is "yes," you must submit a full explanatory statement on a separate sheet attached to this form. The School will undertake to expeditiously review your request for enrollment; however, you may not register until the review is complete. False or incomplete responses will result in a disciplinary action, cancellation of registration or invalidation of credits earned. If any box is checked "YES," additional documentation and/or further consideration by the Admissions Review Board may be required.

Have you been found guilty by any school authorities or by any court to have disrupted or interfered with orderly conduct, processes, functions or programs by any educational institution?

Yes No Not Selected

Have you been charged with a violation of the law, misdemeanor and/or felony (even if adjudication was withheld) which resulted in, or, if still pending could result in, probation, community service, restitution, a jail sentence or the revocation or suspension of your driver’s license (you are not required to include traffic violations which only resulted in a fine)?

Yes No Not Selected

I certify that the above information is correct and complete and understand that falsifying or withholding information may result in disciplinary action and withdrawal from the School. I agree to abide by the policies of the Florida Board of Education and the rules and regulations of this School.

Certification Signature

Certification Date

Healthcare Credentials

Do you have a current healthcare license/certificate?

LPN

Other

OCCUPATIONAL LICENSE: (Attach copy of license/certificate.)

Date Issued

State Where Issued

License and Number

Copy of License or Certificate

Important. You must read and sign the following section in order to complete your application to Hearts Associate Institute. Failure to answer these questions will delay processing of your application. If you answer yes to any of the following, you must submit a full statement of relevant facts on a separate sheet attached to this form. You may be required to furnish the School with copies of official documentation explaining the final disposition of the proceedings. If any box is checked “YES”, additional written documentation and/ or further consideration by the Admissions Review Committee may be required.

A, Are you currently or have you ever been charged with or subject to disciplinary action for educational or any other type of misconduct at any educational institution?

Yes No Not Selected

B. No Have you ever been charged with a violation of the law that resulted in, or, if still pending, could result in probation, community service, a jail sentence, the suspension of your driver’s license (including traffic violations that resulted in a fine of $200 or more)?

Yes No Not Selected

I certify that the above information is correct and complete and understand that falsifying or withholding information may result in disciplinary action and withdrawal from the School. I agree to abide by the policies of the Florida Board of Education and the rules and regulations of this College.

Student's Signature

Please Answer the Following Questions:

1. Do you work in the medical field?

Yes No Not Selected

2. What is your job title? (If unemployed, write N/A.)

3. Are you interested in a life-long career as a nurse?

Yes No Not Selected

4. What has influenced your decision in becoming a nurse?

5. What do you think is the role of a nurse?

6a. Benefit of being a nurse

6b. Benefit of being a nurse

6c. Benefit of being a nurse

6d. Benefit of being a nurse

7. Have you ever cared for an ill person other than a family member? (If no, skip to 9.)

Yes No Not Selected

8. How do you feel when caring for an ill nonfamily member?

9. As an applicant, you are required to write a short essay on why you wish to become a nurse. Please write legibly (or print) in your own words your reasons.

Application Signature

Applicant's signature

Date applicant signed

Guardian’s Signature (If Applicant is Under 18)

Date Guardian signed

Enter the above code

Required