Lubbock Hair Academy                                                      Enrollment Application This application is designed for the staff of Lubbock Hair Academy to get to know the applicant.  The information from this application will help the staff learn the intentions, attitudes, and desires of the prospective student in attending this institution.   Full Name:  _________________________________________________________                FIRST                        MIDDLE                        LAST Address:  ___________________________________________________________ City:  ______________________     State:  __________       Zip:________________ How long at your present address?  _______________ Phone:  (       )  ____________________________ What was your previous address: __________________________________________ How long at your previous address:  _______________________ Birth Date:  ________________________       Birth Place:  ____________________ Are you a citizen of the United States?  ________ If “no” give name of country.  _______________ Social Security Number:  ____________________________________ Education Background Date you expect to enroll:  __________________________________ Education        Name of School        Year Completed        Graduate        Type of Course High School__________________________________________________________________ College_________________________________________________________________ Other___________________________________________________________________ If you did not graduate from high school, do you have a GED?   Yes____   No_____ Military Record:  Branch____________  Entry Date_______ Date Discharged_________ Please describe your duties and any special training you received. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _____________________________________________ Personal References Please list three(3) personal references other than family members. Name:                        Address:                Telephone:                Occupation: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Personal Information Please answer the following questions honestly.  Lubbock Hair Academy seeks out prospective students that are motivated and interested in entering the hair/nail career. Lubbock Hair Academy seeks to select qualified students without regard to race, creed, religion, sex, age, national origin or disability. Marital Status:     ____ Single     ____Married     ____Separated     ____Divorced Have you ever been convicted of a crime, excluding misdemeanors?  ____Yes  ____ No If yes, please describe in full. _________________________________________________________________________________ _________________________________________________________________________________ _____________________________________________________ Person to be notified in case of emergency: ________________________________________________________________________ Name                                        Address                                        Telephone #  Tell us about yourself.   _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Please give any additional information that you wish to be considered in the decision to admit you.   For example: a. Exceptional hardship, set-back, or personal experience that has shaped your abilities. b. Personal responsibilities c. Exceptional achievements or special talents d. Goals e. Ways you may be associated with the institution. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Please tell us why you chose to enter this profession and the expectations you have of attending Lubbock Hair Academy. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ I certify that the information on this application is accurate and complete and subject to verification by Lubbock Hair Academy.  I authorize such verification and release from liability any person giving or receiving such information.  I understand that any misrepresentation or omission of facts would be detrimental to this application and may be cause for preventing my being accepted as a student.  This application does not constitute a contract of admission. Signature                                                        Date _______________________________                 _________________________________