New Application for Admission 2NP(a)

First Name

Required

Legal First Name (if different)

Middle Name

Last Name

Required

Street

City

State/Province

Zip/Postcode

Please upload a digital copy of your High School diploma OR GED certificate OR transcript from a school in the US in any of the following file formats: gif, jpg, jpeg, png, rtf, pdf, doc, docx, odt, or odp.

Required

Phone Numbers

Home Phone

Cell Phone

Required

Work Phone

Preferred Phone Number

Required

Email

Required

Birth Date

Required

Place of Birth:

City, State, Country

How do you self-identify (Gender)?

What is your pronoun?

Social Security No

Required

Marital Status

Financial Dependency Status

Spouse's Name:

How Many Members are in Your Household?

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Program

Required

Campus

Required

Schedule

Required

Start Date

Required

Benefits Sought: I am enrolling in this course/program because

Required

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Is this your first time entering a certificate/degree program?

Yes No Not Selected

Are you a Veteran?

Yes

No

Have you ever qualified for government programs such as (check all that apply)?

Have you ever applied for, or received tuition funding through FAFSA?

Yes No Not Selected
(FAFSA is the Free Application for Federal Student Aid)

Required

How you will pay your tuition:

Required

If other, please specify.

Medical Employment

Employer

Position

City, State, Country

Dates of Employment

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Employer

Position

City, State, Country

Dates of Employment

Other Employment Information

Current Employment Status

Required

Employer

Required

Position

Required

City, State, Country

Required

Dates of Employment

Required

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Medical Training

Institution

City, State, Country

Year of Graduation

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Institution

City, State, Country

Year of Graduation

Other Educational Background:

High School

City, State, Country

Year of Graduation or GED

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College

City, State, Country

Year of Graduation

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Other Training

City, State, Country

Year of Graduation

Please describe in 5-6 sentences what you have liked and not liked about your educational experience so far

Career Goals

Desired Job Role

Desired Income

Desired Location

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Why Do You Want to Become a Medical Assistant?

2-3 Sentences

Does your family support your efforts to complete a full-time program? How?

Please check all foreseeable obstacles to completing a full-time program:

If other, please explain

List any language you speak other than English.

Emergency Contact Information

Emergency Contact 1 Information

Contact Name

Relationship

Home Phone

Work Phone

Cell Phone

Email

Emergency Contact 2 Information

Contact Name

Relationship

Home Phone

Work Phone

Cell Phone

Email

Bay Area Medical Academy reserves the right to require a physician’s approval if it determines that any past or current illnesses or injuries (physical, mental, emotional) would in any way hinder the student’s successful program completion.

Applicant's Allergy Information

Explain any habitual use of drugs, including alcohol, tobacco:

If you have served in the U.S. Armed Forces, please provide the branch of service and approximate dates of military service:

Military Branch:

Dates:

Military Services

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Have you ever been convicted of a serious crime (felony)?

Yes No Not Selected

If yes, please provide details.

Please be reminded that having a criminal background may prohibit your employment efforts in the healthcare field. It is your responsibility to verify whether your criminal background will affect your chances of obtaining a California State License of Phlebotomy. Please ask an Admissions Representative for the appropriate contact information.

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Where or how did you hear about the school?

Required

If other, please write in

Students with special needs due to disability should advise the Academy prior to enrollment to assure that reasonable accommodations can be made to facilitate training. Please describe your needs.

Special Accommodations:

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Bay Area Medical Academy reserves the right to deny admission to any applicant who does not demonstrate the ability to benefit from the training program.

Bay Area Medical Academy does not discriminate on the basis of Race, Color, National Origin, Sex, Handicap, or Age in employment, admissions or any of its educational programs or activities.

IF YOU ARE UNDER 18 YEARS OF AGE YOUR PARENT OR GUARDIAN MUST ALSO SIGN THIS APPLICATION.

The above information is true to the best of my knowledge

Yes No Not Selected

Required

Applicant Signature

Required

Parent/Guardian Signature

Scrub Order

Sizes are unisex.

Program Selection

Required

Scrub Size

Required

Other Size

Scrub sizes are one size bigger and only come in one size sets. Once scrubs are opened you cannot return.

I understand that while attending student lab practice, I may be exposed to blood, body fluids, or tissues. I will use the appropriate personal protective equipment, including but not limited to gloves, gowns, and masks, required when there is an inherent potential for mucous membrane or skin contact with blood, body fluids or tissues, or a potential for spills or splashes of them.

Enter the above code

Required