Application Form – https://wonderhealth.training

Application Form

WONDER HEALTH CAREER INSTITUTE

17440 FM 529 SUITE 106 A

HOUSTON TEXAS 77095

NURSE AIDE APPLICATION

STUDENT INFORMATION

Application Date

First Name

Middle Name

Last Name

Date of Birth

Sex

Marital Status

SS number

Driver’s License number

Driver’s License Country

Home Phone number

Cell Phone number

Email

CLASS SECTION

Month you want to begin program

Please check

In-Person class

How did you hear about us?

CURRENT ADDRESS

Please give your current address for all admission correspondence, if different from above

Address

Street Address

City

State

Zip Code

Country

CITIZENSHIP

Address

Place of birth

City

State

Country

US Citizen

Permanent Resident

Alien registration number

Other Citizenship

ETHNICITY

Race /ethnicity information is optional. Information you provide will not be used in a discriminatory manner

Are you a Hispanic or Latino?

Yes

No

How would you describe your Racial background (select one or more of the categories)

Asian

Black or African American

American Indian or Alaska Native

Native Hawaiian (or other Pacific Islander)

White

ACADEMIC INFORMATION

High schools

Graduation Date:

City/ State

Did you receive GED?

Yes

No

Other college/Universities:

Graduation Date:

City/ State

EMERGENCY CONTACT

First Name

Last Name

Sex

Phone Number

Address

CRIMINAL BACKGROUND INFORMATION

Other than traffic offenses, have you ever been convicted of any misdemeanor, felony, or other crime?

Yes

No

If you answered yes to either question, please provide an explanation and the approximate dates of each incident. Please share your response.

BACKGROUND CHECK AUTHORIZATION

I certify that information contained in this application is correct to the best of my knowledge. I understand that any misleading information contained in this application may result in dismissal from the program. I conﬁrm all information in this application (including any supplemental information) is factually true and honestly presented and that you consent to criminal history background check.

First Name

Last Name

Date

MEDICAL & CRIMINAL RECORDS RELEASE AUTHORIZATION FORM

I hereby, authorize Wonder Health Career Institute to release copies of my medical records, including results of my criminal background and drug test to personnel and officials of School, the Clinical sites or Externship sites, if applicable, for the purpose of determining my eligibility for registration, and/or to qualify to perform my clinical or Externship requirements at their facility.

First Name

Last Name

Date