Home – Olathe, KS – Neyand School of Nursing

Application Form

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Prospective Student Information

Prospective Student Name*

Date Of Birth

Address

State

Zip Code

Phone Number*

Last 4 Digits SSN

Email Address*

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Emergency Contact Person Information

Name

Relationship

City

State

Zip Code

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Prospective Student Educational Background (answer the questions below)

Have You Graduated From High School? Yes------/No------ if yes, tell us the graduation year and the name of the highschool.

Have You Ever Taken GED, ACT or SAT Tests? Yes------/No------ if yes, tell us your score and the year you took the test.

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List of schools attended from high school to universities including vocational schools etc...

School Name

School Address

City/State/Zip

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Degree/ Certificate

School Name

School Address

City/State/Zip

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Degree/ Certificate

School Name

School Address

City/State/Zip

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Degree/ Certificate

School Name

School Address

City/State/Zip

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Degree/ Certificate

How Did Your Hear About Us?

Have you ever applied to the Neyang School of Nursing before?

Why are you interested in taking this course? (Briefly state your answer below)

Have you ever been accepted or denied from a C.N.A or CMA program before? Yes / No. If yes, tell us what happened.

Have you ever been convicted of a misdemeanor, felony, plead guilty or no contest in any state or jurisdiction? Yes / No. If yes, briefly describe the circumstance of your conviction.

Can we have the permission to conduct your criminal background check and your social security verification?

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Reference Information (You can provide up to two references)

Reference # 1:

Reference # 2:

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Class Information:

What class are you applying for? Select one

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Please attached a signed copy of your Enrollment Agreement here if available. The Enrollment Agreement PDF can be found at the top of this page.

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Signature/ Authorization

I hereby make application for selection to Neyang School of Nursing and declare that the information on this application is complete and accurate, and that any misrepresentation, falsification, omission or any attempt to deceive the Neyang School of Nursing can be used to deny my future application to the school, or to cancel my enrollment.

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