STUDENT REGISTRATION FORM
PLEASE READ CAREFULLY BEFORE MAKING ANY ATTEMPT TO COMPLETE THIS FORM
(BLOCK CAPITALS)
SECTION A – PERSONAL DATA
1. Name
Title
Miss
Last Name/Surname
First Name
Middle Name(s)
Mrs.
Mr.
2. a)
Permanent Address: Apt/Street/PO Box
City/Town/Post Office
3. a)
Parish/County
City/Town/Post Office
b) Home/Permanent Phone
(
)
Mailing Address (if different from 6): Apt/Street/PO Box
Parish/County
b) Mailing Address Phone
-
(
c) Cell Phone
c) Name of Contact (if any)
)
-
d) Work Phone
(
)
d) Name of Contact (if any)
-
(
)
e) Email Address
-
Ext:
e) Work Phone
(
)
f) Email Address
-
Ext:
6. If answer to question 4 is yes, please state the following:
4. Have you previously applied to the National
a) National Academy
Identification Number/Index
Number
Academy?
Yes
No
5. Have you previously been a student at the
Nursing
No
7. Gender
Identification Number
EC
Pre-University
8. Date of Birth (dd/mm/yyyy)
Female
10. Marital Status
Single
Divorced
Male
______/______/____________
11.Religion/Denomination
Married
Widowed
Common Law
12. Country of Birth/National of
Yes
Business
9. TRN /Social Security Number
Do you have any child/children?
Yes
No
If yes how many? ______________
14. a) Country of Residence
13. Country of Citizenship
15. a) Do you have a disability? (This information is needed in case special facilities are
required)
c) To (year)
e) Programme
National Academy?
Yes
b) From (year)
b) If yes, please specify
No
SECTION G – HEALTH CONDITION
16. Do you suffer from any of the following illnesses? Please tick.
Yes
No
Asthma
Heart Condition
Kidney Ailment
Hypertension
Other (specify):_____________________________________________________________________________
©National Academy
Version 1.1; 16-11-09
17. Emergency Contact Information:
a) Name
Title
Last Name/Surname
Miss
First Name
Middle Initial
b) Relationship to Applicant
Mrs.
Mr.
c)
Permanent Address Apt/Street/PO Box
d)
Emergency Contact Home/Permanent Phone
(
)
Emergency Contact Cell Phone
(
)
Emergency Contact Work Phone
e)
City/Town/Post Office
Parish/County
f)
(
)
18. How did you obtain information about the National Academy?
Directory
Employer
Internet
Media
School/College Fair
School Visit
Other : Please specify _______________________________
SECTION B – PROGRAMME APPLYING FOR
19. Choice of Course
Ext:
19. Scheduling
Healthcare Assistance (Practical Nursing)
Day (Full Time)
Early Childhood
Healthcare Assistance Level 2 & 3 only
Evening (Part time)
Business Administration (Secretarial Studies)
Pre-University (Academic)
Day Release
Home Care Nursing
Paediatric Nursing
Geriatric Nursing
SECTION C – EXAMINATION RECORDS
20. Examining
Body (e.g. CXC,
Cambridge)
Level
Subject
Grade
Date Awarded
(mm/yyyy)
CXC (CSEC) General Proficiency and GCSE Ordinary Level subjects passed
21. List academic programmes or examinations for which you are currently preparing or awaiting examination results.
Examining Body
Level
Subject/Programme
(e.g. CXC, CSEC,
GCE)
Date of Exam
(dd/mm/yyyy)
Grade
[official use
only]
5
©National Academy
Version 1.1; 16-11-09
22. List educational institutions attended and any other programmes or courses you have completed, from Secondary school to present.
Institution Name & Address
From
(mm/yyyy)
To
(mm/yyyy)
___/________
______/__________
___/________
______/________
_____/_______
_____/__________
23. Please list any sporting/community/cultural or social activities in which you have been involved.
SECTION C – FINANCIAL RESOURCES
24. Source of Funding
Government (specify):__________________________
Loan
Self
Spouse
Donor (specify):_______________________________
Parents
Award
(specify):______________________________________________
25. Will you be able to meet your financial obligation for the entire course/Marmicmon LPN Program?
Yes
No
a) Name of Person responsible for payment of tuition fee
Is this person currently employed?
Yes
b) Name of Organisation responsible for payment of school fee
No
Name of Organization
Name of Contact Person:
Position
Department :
Address: Apt/Street/PO Box
Address: Apt/Street/PO Box
City/Town/Post Office
Telephone Number
(
)
-
Parish/County
Fax Number
(
)
Email Address
-
City/Town/Post Office
Telephone Number
(
)
-
Parish/County
Fax Number
(
)
Email Address
-
SECTION D - EMPLOYMENT RECORD
26. List employment information starting with your current job
a) Name of Employer
Position
How Long?
Address: Apt/Street/PO Box
b) Name of Employer
Position
How Long?
Address: Apt/Street/PO Box
City/Town/Post Office
State
Parish/County
©National Academy
City/Town/Post Office
Parish/County
Version 1.1; 16-11-09
SECTION E – REFEREE INFORMATION
SECTION F - DECLARATION
28. I hereby certify that I have read and understood the instructions and the
29. This application is made with my consent and I intend to provide such fees as
information necessary for completing this application and that all statements made may be payable to the Institution.
are true and complete. I intend to provide such fees as may be payable to the
National Academy. I understand that otherwise my admission to or registration in
the Institution may be revoked.
_______________________________
Signature of Applicant
______/______/___________
Date (dd/mm/yyyy)
__________________________________
Signature of Parent/Guardian
______/______/____________
Date (dd/mm/yyyy)
FOR OFFICIAL USE ONLY
Original Documents Returned:
Documents Received:
Passport Picture
Medical Form
Birth Certificate/National ID
Proof of Age
Financial Commitment Letter
Signed Guidelines
__________________________________
Signature of Applicant
______/______/____________
Date
(dd/mm/yyyy)
__________________________________
Signature of Administrator
______/______/____________
Date
(dd/mm/yyyy)
Transcripts/School Record or Report
Academic Qualifications eg. (CXC)/GCE
High School Diploma
Other (specify):_______________________________________________
RESULTS FOR ENTRANCE TEST:
MATHEMATICS ______ ENGLISH LANGUAGE _______ GENERAL KNOWLEDGE ______
Interviewed by:_____________________________ Date:_______________________
Interviewed by:_____________________________ Date:_______________________
Interviewers’ Comments:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
©National Academy
Version 1.1; 16-11-09