New Application for Admission 2NP(a)

Application for Admission 2NP(a)

Preferred First Name

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.

Preferred Phone Number

Place of Birth:

City, State, Country

How do you self-identify (Gender)?

What pronoun do you prefer?

Financial Dependency Status

How Many Members are in Your Household?

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

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

Yes No Not Selected

Are you a Veteran?

Yes

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

SNAP

SSI/SSDI

WIC

WIA/WIOA

DOR

CalWorks/TANF

work2future

DACA

Unemployment

CalFresh

None of these

*If you qualify for any of these programs we may be able to assist you with locating and applying for tuition funding

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

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

How you will pay your tuition:

Self Pay

FAFSA

Employer

Scholarship

Other

Public Agency (Unity Council, WIOA etc)

If other, please specify.

City, State, Country

Other Employment Information

Current Employment Status

City, State, Country

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City, State, Country

Other Educational Background:

City, State, Country

Year of Graduation or GED

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City, State, Country

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

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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:

Transportation

Work Schedule

Kids / Daycare / Babysitter

Financial

Caregiving for family

Attendance

Punctuality

Other

If other, please explain

List any language you speak other than English.

Emergency Contact Information

Emergency Contact 1 Information

Emergency Contact 2 Information

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:

Dates:

Military Services

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.

Where or how did you hear about the school?

Facebook

Twitter

Instagram

Postcard/Brochure

Bus ad

Newspaper ad

Radio ad

Google ad

Mall ad

Facebook ad

Blog post

Online search

Yelp

Friend/Relative

Other

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

Parent/Guardian Signature

Scrub Order

Sizes are unisex.

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

Application for Admission 2NP(a)

Phone Numbers

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Medical Employment

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Other Employment Information

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Medical Training

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Other Educational Background:

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Career Goals

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Emergency Contact Information

Emergency Contact 1 Information

Emergency Contact 2 Information

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.

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

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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.

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Scrub Order