LifePoint Career Institute
Application for Admission
Office of Admission  1225 West Beaver Street  Jacksonville, FL 32204
(904) 265-4750  www.freshministries.org
NURSING ASSISTANT PREP PROGRAM___
HOSPITALITY PROGRAM___
A. Demographic Information
Social Security Only The Last Four #
Name
First
 Male
Female
Last
Middle
Birth date (mm/dd/yyyy)
Place of birth
City
State
Address
City
State
Zip Code
County
Country
Phone (enter 10 digit #)
Cell (enter 10 digit #)
Email Address:
Mailing address (if different from above)
City
Country
State
Zip Code
County
Country
Note: The mailing and email address you provide will be your addresses of record. It is your
responsibility to maintain current contact information on file with the institution.
Have you ever been known under any other name(s)
If yes, list name(s):
 Yes
 No
Will documents be received in another name?
If yes, list name(s):
 Yes
 No
B. Personal Data
How did you hear about us?
 Agency: ___________________________
 Friends/ Relatives
 Media Advertisement
 Career/Job Fair
Race:
 Caucasian
 Other
Marital Status:
 African American/Black
 Single
Are you TANF eligible?
 Recruiter
 Former Student: ___________________
 Flyer
 Other: ___________________________
 Married
 Yes
 Hispanic
 Asia/Pacific Islander
 Separated  Divorced
 No
Are you receiving public assistance (check all that apply)
 Cash Assistance If yes to Cash Assistance please list Worker’s Name_______________________
 Medical  Food Stamps  Transportation  Subsidized Child Care
□Highest level of education you completed:  High School /GED
 Bachelors
□ GED PROGRAM
Are you currently enrolled in school?
 Yes
 No
Are you physically disabled?
 Yes
 No
Are you a Veteran?
 Yes
 No
 Associate Degree
 Masters
Are you a Citizen of the USA?
 Yes
 No
If you are not a US Citizen, indicate your present legal status:
 Permanent Visa
 Other
If other, please explain: ________________________________________________________________
__________________________________________________________________________________
Have you ever been convicted of a Felony or Misdemeanor?
 Yes
 No Date: ___________
If yes, give details: ______________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever been arrested?
 Yes
 No
Date: _________________
Are you a Jacksonville Housing Authority Resident?
 Yes
 No
If yes, where: ________________________________________________________________________
Emergency Contacts:
Name: ___________________________________________
Relationship: ________________________________________________________
Telephone:_______________________________________ Mobile: __________________________
Name: ___________________________________________
Relationship: ________________________________________________________
Telephone:_______________________________________ Mobile: __________________________
Applicant’s Signature:
The statements I have made in this application are correct to the best of my knowledge. I understand
that any misrepresentation or omission of facts requested in this application is cause for
disqualification for admission or for dismissal from LifePoint Career Institute. I agree to conform to all
rules and regulations of LifePoint. I also agree to give LifePoint permission to share criminal
background with potential employers.
LifePoint Career Institute does not discriminate on the basis of age, sex, color, disability, marital
status, race, religion, ethnic, or national origin.
___________________________________________________
Signature
For office use only
NURSING ASSISTANT PREP PROGRAM___
______________________
Date
HOSPITALITY PROGRAM___
Date Application received/by: _______________________________________________
Scheduled Appointment Time_________________________
Client Informed by ________________________Date/Time____________________________
Left Message_______________________ ________________________
Client Request to be Rescheduled __________________________________
Interview
Essay completed _______Background Check Completed ________HS/GED copy__________
File reviewed by:____________________________ ______________________________
Interviewed by: __________________________ ______________________________
____________________________________ _________________________________
Date admitted: _________________________________________
Date of declination________________________ Date letter issued :______________________
Certification completed:
Withdrew
NOTES:
/
/
 YES
 No
Expelled
/ /