Brighton Institute of Cosmetology
10543 Citation Drive
Brighton, MI 48116
810 229-5066
Fax 810 229-4561
www.brightoninstitute.net
APPLICATION FOR ADMISSION
______________________________________________________________________
General Information
Name _______________________________________________________________ ____ Social Security No. _ _ _/_ _ /_ _ _ _
Last
First
Middle
Current Mailing Address_____________________________________________________________________________________
Street
City
State
Zip
Home Address____________________________________________________________________________________________
(If different from above)
Street
City
State
Zip
Home Phone (___) _________________ Work Phone (____) ________________Cell Phone (___) _______________________
Cell Phone Carrier ______________________E-mail Address _____________________________________________________
Date of Birth____/___/_____ Sex: M___ F ___ Driver’s License # ____________________________________
Marital Status:
Single_______
U. S. Citizen or U. S. Resident:
Married ______
Yes____
No____
Separated ______
Divorced ______
DL State _____
Widowed______
Birthplace___________________________________________________
Employer_________________________________________________________________ __________Phone_ (___) __________
Address__________________________________________________ ____________City______________ State____ Zip_______
Have you ever been convicted of a felony or currently awaiting trial on felony charges?
Yes _____
No _____
If yes, explain in detail______________________________________________________________________________________
________________________________________________________________________________________________________
Are you on probation or parole?
Yes _____ No _____
If yes, explain in detail including name and telephone number of probation officer_________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
(The prospective student must contact the State Board to determine whether they are eligible to apply for a license.)
Educational Information
Please circle last grade completed
9
10
11
12
High School
GED ( )
Year (
Vocational-Technical School
)
1
2
College
1
2
3
4
High School Name _____________________________High School Counselor______________________________
Post Secondary School (s)
Course (s)
Degree (s)
_________________________
__________________________
_______________________
_________________________
__________________________
________________________
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Family Information
Father
Mother
Name ______________________________________
____________________________________
Address ____________________________________
____________________________________
___________________________________________
____________________________________
Wk. Ph. (
) _______________________________
Wk. Ph. (
) _________________________
Home Ph. (
) _____________________________
________________________
Cell Ph. (
Home Ph. (
) ______________________________
Cell Ph. (
)
) ________________________
Two Additional References of persons who are likely to know your address in the future years.
Name _____________________________________
___________________________________
Address ___________________________________
____________________________________
City______________________________ State____
___________________________State ____
Phone (
) ________________________________
(
) ________________________________
In case of an Emergency, Notify: ___________________________________________________________________
Relationship _______________________ Home Ph. (
) _________________Work Ph. (
) ________________
Address______________________________________________________________________________________
City
State
Zip
_____________________________________________________________________________________________
Disabilities *
Do you have any physical impairment which might affect your training at Brighton Institute of Cosmetology?
Hearing Loss
Yes___ No ___ Percentage___
Heart Condition
Yes____ No____
Sight Loss
Yes___ No___ Percentage ___
Hernia
Yes ___
No____
Color Blindness
Yes ___No___
Tuberculosis
Yes ___
No____
Nervous Disorders
Yes___ No___
Diabetes
Yes ___
No____
Convulsions
Yes___
No____
Other (explain) _________________________________________________________________________________
*You are not required to answer these questions. However, it will help us serve you better, assist us in planning, and avoid
unnecessary mistakes in correspondences.
_____________________________________________________________________________________________
Health Survey
Mark appropriate answers. Please answer all questions.
Are presently under a doctor’s care for a physical problem?
Yes ____ No ____
Are you presently under a doctor’s care for an emotional problem?
Yes ____ No____
Do you take any prescribed medication or drugs frequently for the following?
( ) Diabetes
2
( ) Epilepsy
( ) Cardiac Condition
( ) Hypertension
( ) Asthma/Hay Fever
Do you have a sight or coordination problem that limits your mobility?
Yes ____ No ____
Do you have an impairment that causes you to walk with difficulty or
Confines you to a wheelchair?
Yes ____ No ____
_____________________________________________________________________________________________
Essay
Please write a paragraph stating why you would like to become a Cosmetologist/Nail Technician/Esthetician or
Instructor
_____________________________________________________________________________________________
How did you first learn about Brighton Institute of Cosmetology? (Check all that apply)
____High School Counselor
____Employer
____Career Day
____Family Member
____Newspaper Ad
____Radio
____Yellow Pages
____Friend/Acquaintance
____Internet
____Magazine Ad
____Television
____Salon/Spa
Other (Please Specify) __________________________________________________________________________
Who (other than you) most influenced you in your final decision to enroll at Brighton Institute of Cosmetology?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Payment Policy and Registration
A deposit is required at the time of registration. The deposit for Cosmetology is $1,200.00. The deposit for Esthetician and
Manicuring is $1,210.00. The deposit for Instructor’s course is $900.00. Acceptable forms of payment are cash, check or Visa and
MasterCard. Also you must present a copy of your Birth Certificate or Driver’s License along with a copy of your High School
Diploma or GED. If you graduated from high school or obtained a GED certificate but are unable to provide the actual
documentation you must provide an original transcript. All diplomas from countries outside the USA must be evaluated by an
approved Foreign Credential Evaluator before enrollment. Online diplomas are unacceptable unless they can provide
documentation for National Accreditidation.
_____________________________________________________________________________________________.
Classes
____Cosmetology
____Manicuring
____Esthetician
____ Cosmetology Instructor
_____ Limited Instructor Manicuring/Esthetician
Transfer: Previous training at Hours_______________________________________________________________
_____________________________________________________________________________________________
I wish to apply for admission for the month of:
____January
____February
____March
____ August
____September
____ October ____November ____ December
3
____April
____May
____June
____July
FINANCIAL AID AVAILABLE FOR COSMETOLOGY CLASS ONLY
_____________________________________________________________________________________________
Financing Your Education
If you need Government financial assistance to attend Brighton Institute of Cosmetology you (and/or your family) will need to
complete a FAFSA application to determine if your eligibility. You can obtain this form from the Director of BIC or by going to
www.Fafsa.ed.gov. These will serve as an application for the Pell Grant and/or student loans. To determine qualifications as
FAFSA must be completed.
Check the appropriate selection:
Already Applied (give date)
Plan to Apply
o
FAFSA
_______________
______________
o
Student Aid Report
_______________
______________
o
Student Loan
_______________
______________
o
List other Aid or Sponsors
____________________
_______________
______________
____________________________________________________________________________________________
I wish to apply for admission for the month of:
____January
____February
____March
____April
____May
____ August
____September
____ October ____November ____ December
____June
____July
_____________________________________________________________________________________________
_______
I submit this application as a true statement of fact for your consideration.
Applicant Signature ____________________________________________________________Date_____________
Parents Signature (if under legal age)______________________________________________ Date_____________
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