Academy for Nursing and Health Occupations
A Private, Not-for-Profit, Licensed and Nationally Accredited College of Nursing
    

Where dreams of a Better Tomorrow Come True … Learn, Grow, Become …


Located at:
5154 Okeechobee Blvd
West Palm Beach, FL 33417
Phone: (561)683-1400
Fax: (561)683-6773
Email Us 


  
Lois M. Gackenheimer, PhD Ed, MSN, RN
Executive Director / President
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Online Application



 
You must fill in all fields and submit the form in order for it to be received by the school.

 How did you hear about ANHO?

Last Name:
First Name:
Middle Initial:

Social Security Number:
Date of Birth:
Age:

Address:
City:
State:
Zip:
Phone #:
Cell #:
Email Address:

US Legal Status:


Health HistoryPlease list disabilitiesPlease explain any
accomodation you will need
Physical Problems  
Hearing Problems  
Speech Problems  
Sight Problems  
Emotional Problems  
Other:   

    In the last 5 years, have you been enrolled in, required to enter into, or participated in any drug or alcohol recovery program or impaired practitioner program?
    In the last 5 years, have you been treated for or had a recurrence of a diagnosed mental disorder or impairment?
    In the last 5 years, have you been treated for or had a recurrence of a diagnosed physical impairment?
    In the last 5 years, have you been treated for or had a recurrence of a diagnosed addictive disorder?

Education Level
    Graduated From High School
    Received GED
    Bachelor's Degree Obtained

Please list all schools attended beginning with High School:
School NameAddressCourse of StudyYears AttendedDegree/ Diploma Earned

Transportation
    Drivers License
    Restricted License
    Students are required to travel to a variety of clinical sites. Do you have the ability to comply with this requirement.

Work History
Dates EmployedCompany NameYour Position
1. 
2. 
3. 
4. 
5. 
6. 

I am presently employed at:
Company Name & Address:
Position Held:
Supervisor:
Phone #:
Salary:

I have been laid off from:
Company Name & Address:  

Are you a US Military Veteran?  (Please Check One)
  If so, are you eligable for GI Bill®Benefits?  
  Are you planning to use your GI Bill®Benefits?  

List any skills, certifications, licenses or special training you have:

Criminal Background:
    Have you ever been convicted of, or entered a plea of guilty, nolo contendre, or no contest to, a crime in any jurisdiction other than a minor traffic offense? You must include all misdemeanors and felonies, even if adjudication was withheld and even if you were a juvenile. Driving under the influence (DUI) or driving while impaired (DWI) is not a minor traffic offense for the purposes of this question.

Please Explain: *You must have arrest and court records of final disposition for each offense listed.


Program Applying For:  


In the event that we are unable to contact you at the phone number you have given please provide two(2) additional contacts:
NameRelationshipPhone Number

In connection with my application to the Academy for Nursing and Health Occupations, I understand that a consumer report, which may contain public records information is being requested


Electronic Signature      Date  
(Typing your name here is equivilant to signing the application by hand)