|Date of Birth|
|Home Phone (xxx)xxx-xxxx|
|Work Phone/Alternate Contact:(xxx)xxx-xxxx|
|Emergency Contact Person|
|Emergency Contact number: Cannot be the same as cell or home|
|Nearest Relative(relationship to student)|| Mother
|Nearest Relative Phone Number|
|What is the best time to reach you?|| Morning 8am - 11am
Day 12pm - 5pm
Evening 5pm - 8pm
|Name of High School/Secondary School|
|Date of Graduation|
|Name of College (If any)|
|Are you employed? (Please complete below)|| Yes
|Employer's Phone Number|
|Select Admissions Representative|
|Do you have a computer?|| Yes
|Which program are you applying to?|
|The fee to apply for admission to Orion College is a non-refundable application fee of $50.00(US currency.) This fee is used to administer the entrance exam and to process your application, transcript requests, and financial assistance applications. Thank you.|
|How did you find out about our program?|
|Previous Education|| High School
|Are you dependent or independent (please read below)|| Dependent
|Are you under the age of 18?|
|If you are under 24, you are considered independent if any of the following applies to you:
1. A graduate or professional student.
3. A student with legal dependents other than a spouse.
4. A veteran of U.S. Armed Forces.
5. An active duty member of the U.S. armed forces (not for training purposes)
6. An orphan or ward of court.
|Please provide the full name of your parent or legal guardian|
|Are you currently attending a school or college?
|Please select one|| Yes
|If so? Please provide name|
|Criminal Background Disclosure|
|Please be advised that you may be asked to furnish a background check prior to clinical/externship hours. If you have ever been convicted of, pled nolo contendere (no contest) to, or had adjudication of guilt withheld for any violation of any state or federal law in any jurisdiction, this may adversely impact your ability to obtain a certification/licensure or gain employment in the field for which you are trained.|