Public Nursing Assistant Application

Are you currently in high school?

Yes

Current School

Graduation Year

Do you currently work at a healthcare facility?

Yes

Please tell us where you work

Checkmark each statement below to indicate that it is true and accurate *

The information I have provided is correct in all aspects.

I understand that this registration does not imply current or future admission to Bellin College. If I wish to apply for admission into one of the programs of study I must complete a Bellin College application.

I agree to comply with all applicable rules/regulations and policies articulated in the Bellin College – Nursing Assistant Program, Parent/Student Handbook in effect during the enrollment term of my registration.

I understand that the courses taken will be granted college credit at Bellin College and may transfer to another institution only at its discretion, according to its transfer rules.

I understand that completion of this credit will result in the creation of a permanent enrollment record at Bellin College.

I confirm that college policy regarding the Family Educational Rights and Privacy Act (FERPA) and access to my student record was explained to me.

I agree that I am liable for all fees related to this enrollment. I agree to all conditions outlined in the Bellin College Tuition & Fee Schedule.

I understand that enrollment requires payment in full by the first day of class. Payment is refundable if I withdraw prior to first class meeting.

I understand that this State of WI directed program requires attendance at every class. I have no conflicts with my personal schedule that would interfere with this attendance requirement. I understand that Bellin College is not able to offer special requests for missed classes. The make-up dates listed on the course calendar are only for extenuating circumstances associated with illness, emergencies, or weather.

Required Forms

If you have issues uploading here, please email forms to nursingassistant@bellincollege.edu with student's full name.

Nursing Assistant Program Technical Standards Inventory *

Bellin College Media Release Form *

Student Demographic Information Form *

Background Information Disclosure Form *

Signature

Sign by printing your name in the box below

Date

Reservation Fee (non-refundable)
To reserve a spot in our Nursing Assistant program, a non-refundable $200 reservation fee is required.

Payment Form

Amount Due
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Amount Due

BC Family

Visitors

Public Nursing Assistant Application

Nursing Assistant Application