New TPI Enrollment Application

Techni-Pro Institute

414 NW 35th Street, Boca Raton, Florida 33431

TPI Enrollment Application

This application must be accompanied by a $75.00 non-refundable registration fee.

Enrollment Agreement

First Name

Middle Name

Last Name

Birth Date

Street

City

State/Province

Zip/Postcode

Cell Phone

SMS

Social Security No

Gender

Are you a U.S. Citizen?

Yes No Not Selected

How did you hear about us?

VALID ID

Yes No Not Selected

VALID ID

Disability

Yes No

Disability Description

Learning Difficulties

Yes No

Learning Difficulties Description

Emergency contact

Contact Name

Relationship

Cell Phone

Home Phone

Student Employment Verification

Name of Employer:

Street

City

Zip/Postcode

State/Province

Phone

Employed From:

Employed To:

Your Position or Job Title

Current Wages/Salary:

Verified by Staff Member

Last 4 of Social Security Number

NOTE: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction.

I hereby authorize release of my employment information.

Program Application Form

The following items are required in order to be considered for admission to the program: 1. Proof of a high school diploma, GED, or validated foreign equivalent 2. Copies of any post-secondary certificates of health-related course taken (CORE, PCT, PCA, HHA, Medical Terminology, CNA, and MA). 3. Official transcripts of college degrees no later than 1 week of start date. 4. A copy of your FL driver license 5. A copy of your Social Security card 6. FDLE-Level 2 Background screening

Program

Program Start Date

Attended High School or GED?

Yes No Not Selected

High School Diploma or GED

Attended College?

Yes No Not Selected

Attained Degree?

Yes No Not Selected

Upload a copy of your Transcript

Any prior Medical Training?

Yes No Not Selected

If yes, please identify type of training, name of school, dates of attendance, and type of certificate or diploma

RN License Number

RN License Number

Note: If you have taken the TEAS/ KAPLAN/ ATI or HESI Test at an approved school within the past two years, you should request the school to send a copy of your scores to Techni Pro Institute.

Verification of Compliance with Technical Performance Standards

The Health Science Education has outlined specific Technical Performance Standards that serve to inform students of skills and/or physical/psychological demands necessary for program completion and workplace responsibilities.

After review of the Technical Performance Standards for my program of study: I have determined that I will be able to perform the standards or essential skills listed. I have determined that I will be able to perform the standards or essential skills listed but will require reasonable accommodation. I have registered with Disability Services and will arrange to meet with the Associate Dean to determine the accommodation necessary.

Student Initial

Permission to Render Medical Treatment

In case of serious illness or accident, I give Techni Pro Institute or its representative(s) permission to secure medical and/or surgical care to include transportation to a physician or hospital of their choice, examination, medication, and surgery that is considered necessary for my good health. I understand that I am responsible for any cost incurred if not covered by the Health Care Agency Affiliation Contract or by the Health Science accident insurance, and/or another appropriate assisting agency. Nursing students’ physicals are to note if they are taking prescription drugs that have the potential to affect performance in the clinical area. Medical clearance would be requested from the prescribing physician. Information detailed on the Medical History and Physical Examination form is legally privileged and confidential. It is intended for use by the Health Science program unless written consent has been provided for release to other parties.

Student Initial

Release of Information

In conformance with 20 U.S.C. 123g (Family Education Rights and Privacy Act) and Section 228.093, Florida Statutes, I authorize Techni Pro Institute and its agents to release and disclose the information contained in this form, including my immunization record, upon request, to a clinical affiliation site I herein give permission to duplicate the requested information and release it to the clinical site. I do not give permission to duplicate the requested information and release it to the clinical site.

Student Initial:

Declaration

Student Signature

Date

I verify that all information contained in this application is true and correct. I understand any falsification or omission of information may result in my rejection or dismissal by Techni Pro Institute. I further authorize Techni Pro Institute to contact former employers and educational institutes listed on this application and authorize these employers and institutions to release information to Techni Pro Institute.

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