Admissions Application Request - Main Form

Welcome
Personal Information
Address
Parent Information
Education and Employment History
Additional Information

is required

This application is for Nursing programs. If you are interested in applying for an Allied Health or Trades program please click here.

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First Name
Middle Name/Initial
Last Name
Maiden/Former Last Name
Email Address
Social Security Number

Confirm Social Security Number
Date of Birth
Gender
Are you Hispanic or Latino?
Select one or more of the following races:

White

Black or African American

Asian

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander
Citizenship Status
Citizenship Country
Marital Status
INS Classification
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Emergency Contact Information
Country
Street 1
Street 2
City
State
Zip Code Zip Code Extension
Province
Postal Code
Home Phone Home Phone Area Code Home Phone Exchange Home Phone Number Home Phone Extension Ext:
International Home Number International Home Number Extension Ext:
Mobile Phone Mobile Phone Area Code Mobile Phone Exchange Mobile Phone Number Mobile Phone Extension Ext:
International Mobile Number International Mobile Number Extension Ext:
Contact Information
If employed, employer name:
Employer Street Address
Employer City
Employer State
Employer Zip Code Employer Zip Code Extension
Employer Phone Number Employer Phone Number Area Code Employer Phone Number Exchange Employer Phone Number Number Employer Phone Number Extension Ext:

is Required

Employment Information
Economically Disadvantaged:

If you are receiving any funding, other than by employer to attend this class or if you are unemployed you are considered economically disadvantaged. You may also be considered economically disadvantaged if your total annual income is less than these amounts for the total number of persons living in your household:

1 - $18,130 2 - $24,420 3 - $30,710 4 - $37,000 5 - $43,290 6 - $49,590 6 - $49,580 (each additional person add $6290)

Limited English Proficiency:

An individual who was not born in the United States or whose native language is other than English.

Single Parent:

An individual who is unmarried or legally separated from a spouse and has a minor child or children for which the parent has custody or joint custody.

Displaced Homemaker:

A person who has worked primarily without pay as a homemaker, who has diminished marketable skills, who through separation, divorce, widowhood, or disability of spouse has lost a major source of financial support or who has become ineligible for public assistance as the parent of a needy child.

Non-Traditional Student:

Non-Traditional CTE programs prepare students for occupations or fields of work in which individuals from one gender comprise less than 25% of the individuals employed in those occupations or fields of work. Female nontraditional occupations are those where less than 25% of individuals employed are female. Male nontraditional occupations are those where less than 25% of the individuals employed are male.
Emergency Contact Type
Emergency Contact First Name
Emergency Contact Last Name
Release of Information:

I authorize the Collins Career Technical Center to release my educational records, which includes my name, my social security number, student ID number, and date of birth, to the agencies listed below. The agency use of these records is limited to and in connection with the audit and evaluation of Federally-supported education programs, or in connection with the enforcement of the Federal legal requirements, that relate to such programs.

Student/Examinee information released to:

-Ohio Department of Job and Family Services, 145 South Front Street, Columbus, Ohio 4321

-Ohio Department of Higher Learning, 25 South Front Street, Columbus, Ohio 43215

My signature is my acknowledgement that I have read and voluntarily consented to the release of the above-mentioned educational records as collected and utilized by the adult workforce education programs I have previously enrolled in or tested with.
Emergency Contact Phone Number Emergency Contact Phone Number Area Code Emergency Contact Phone Number Exchange Emergency Contact Phone Number Number Emergency Contact Phone Number Extension Ext:
Choosing a Starting Semester

We know that our students need a flexible schedule in order to make their education work in their lives. That's why we offer our nursing programs in several location and times of day.

Main Campus Daytime Classes

- Practical Nursing

Main Campus Evening Classes

- Practical Nursing

Coal Grove Campus Daytime Classes

- LPN to RN Diploma Nursing Program

- Paramedic to RN Diploma Program

- Practical Nursing

Coal Grove Campus Evening Classes

- LPN to RN Diploma Nursing Program

Choose the location and time of day that you would like to take classes to filter your options in the anticipated start date dropbox.

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Current Education Level
If you have graduated from High School or obtained a GED, when did you do so? (Graduation Month)
If you have graduated from High School or obtained a GED, when did you do so? (Graduation Year)
High School/GED Institution

If you have graduated from High School, provide the school name:Opens in a new tab
College Name

Previous training from a post-secondary institution:Opens in a new tab
Program of Interest
Anticipated Starting Date
Are you a US Military Veteran?
Campus/Time of Day

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Type of Admission:
Today's Date (mm/dd/yyyy):
Digital Signature (Please type your full name):
If applicable, what was your name when you attended?
Have you ever attended CCTC Adult Education Training?
If yes, which program and year?
If applicable, what was your name when you attended?
If yes, which program and year?
Have you ever attended CCTC High School?
If so, from where are you dislocated?
If you are unemployed, are you a dislocated worker?
Employment Status:
Are you homeless?
If other, please specify:
If yes, please describe:
Do you have a medical condition that CCTC needs to be aware of for emergency purposes?
I do not have a High School Diploma.
If you have not graduated from High School, when is your planned graduation date? (mm/yyyy)
Please Check the Following, if applicable:

Economically Disadvantaged

Limited English Proficiency

Single Parent

Displaced Homemaker

Non-Traditional Student
If you selected Public Assistance, please specify any types below:

Food Stamps, Only

Medicaid

Subsidizing Housing

TANF
Please provide your Permanent Resident Alien Registration #
Post-secondary Institution 1 Credential Earned
Post-secondary Institution 2 Credential Earned
Post-secondary Institution 1 Dates Attended (mm/yyyy-mm/yyyy):
Post-secondary Institution 2 Dates Attended (mm/yyyy-mm/yyyy)
If you selected some college, please specify (check all that apply):

Technical Certificate

Associate's Degree

Bachelor's Degree

Master's Degree

Doctorate Degree
Are there any special considerations that you need due to (please select all that apply)

Deaf

Developmentally Handicapped

Hearing Impaired

Learning Disability

Seriously Emotionally Disturbed

Speech Impaired

Visually Impaired

Public Assistance

Other Impairment

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