Next Class Start, Feb 9 & 16

Applicant Information

Legal Name (First, Middle, Last) *

Preferred Name *

Date of birth *

Age *

Phone (primary)

Phone (alternate)

Email *

Address *

Street Address

City

State

Postal Code

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By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others from NEEMA INTERNATIONAL MEDICAL INSTITUTE LLC at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

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Fingerprint Clearance / Background Screening

Do have Level 1 Fingerprint Clearance Card *

Yes

No

Applied and will provide by

Do you Need instructions to apply *

Yes

No

Applicant Initials

Prior Names / Aliases

Used another legal name? *

No

Yes

Prior Names

Emergency Contact

Emergency Contact Name *

Emergency Contact Email *

Alternate

Emergency Contact Phone *

Relationship *

Accommodation Request

Need accommodation? *

Yes

No

If Yes Describe

Parent/Guardian Consent (Under 18)

Student Name

DOB

Parent Name

Parent Email

Parent Phone

Parent Signature

Date

Tuition and Payment Acknowledgment

Tuition Amount *

$

Registration Fee *

$

Total *

$

Payment Plan *

Paid in full

Payment plan

Third-party payer

Refund policy provided? *

Yes

No

Program Policies Acknowledgment

Attendance policy understood *

Yes

Professional conduct understood *

Yes

Cell phone policy understood *

Yes

Clinical requirements may be stricter *

Yes

Enrollment contingent on clinical eligibility *

Yes

Applicant Attestation

I certify information provided is true and complete.

Applicant Signature *

Clear

Printed Name *

Quick Links

Legal

Next Class Start, Feb 9 & 16

Applicant Information

Identity and Eligibility

Education Background

Health and Clinical Readiness

Fingerprint Clearance / Background Screening

Prior Names / Aliases

Employment & Availability