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Application and Personal Information Sheet

Personal Information

Name*

First Last

Age*

Date of Birth*

Birth Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Driver's License #*

Social Security #*

Your Place of Employment

Work Phone

Course Information

Course interested in*

Cosmetology
Manicuring
Instructor Training
Esthetics

Month*

Schedule*

Days (40 hrs - Cos. Only)
Days (30 hrs)
Nights (30 hrs)
Nights (20 hrs)
Days (25 hrs - Esthetics Only)

Day classes are Tuesday through Saturday. Night classes are Monday through Friday.

Uniform size needed*

Need iPad*

Yes
No

Shears*

Right
Left

Emergency Information

Do you have any allergies, serious illnesses or any other disabilities that we should know about or are you pregnant?*

Yes
No

Please provide detailed information

(Please include any difficulties in reading or comprehension)

Emergency Contact*

First Last

Emergency Contact Phone*

Education Information

Completed education*

High School Diploma
GED

High School Diploma Received From

Year Received

FAFSA / Financial Information

Are you a Veteran or the child of a Veteran?*

Yes
No

If so, are you eligible for Veteran Benefits?*

Yes
No

Are you currently pregnant?*

Yes
No

If so, what is your due date?

(This is only used to determine dependency status for FAFSA)

Are you in default on a Federal Student Loan?*

Yes
No

Do you have an outstanding balance on a student loan?*

Yes
No

Have you filed bankruptcy?*

Yes
No

Do you give permission to Rudae's to obtain criminal background check and credit report?*

Yes
No

Have you been convicted of a felony?*

Yes
No

How do you plan to finance your education?*

Pell Grants
Student Loans
Monthly Payments
Unsure

Dependent Information

Name of Parent(s) or Guardian(s)

Address

Street Address Address Line 2 City State ZIP Code

Phone

How did you hear about Rudae's?

We would really appreciate knowing how you heard about us

Newspaper
Radio
Television
Yellow Pages
Internet
Referral
Other

Referral by

Please list

Demographic Information

By law, any institution of higher education which offers vocational programs, or receives/applies for or expects to apply for Federal Financial Assistance is required to gather racial/ethnic data to submit to the federal government each year on various IPEDS forms. NACCAS uses the same IPEDS racial/ethnic categories on the NACCAS Annual Report form. To make it easier for you to provide this information, we ask you to please complete this confidential information for your personal file.

Sex*

Male
Female

Date of Birth*

Marital Status*

Single
Married
Widow
Divorced/Separated

Children*

Yes
No

If so, how many?

Race*

Have you attended any other College?*

Yes
No

If so, where?

Consent to be signed by the applicant and parent/guardian (if student is under 18 years of age). In the event of emergency illness or injury, permission is hereby granted to the staff of Rudae's School of Beauty Culture, Inc. to refer this applicant to a local physician. Rudae's is authorized to make all inquiries deemed necessary to verify the accuracy of the information contained herein and to determine the credit-worthiness of the undersigned.

Applicant Signature*

Date*

Parent/Guardian Signature

Date*

Application and Personal Information Sheet

Personal Information

Course Information

Emergency Information

Education Information

FAFSA / Financial Information

Dependent Information

How did you hear about Rudae's?

Demographic Information

Location