Step 1 of 3 33% PhoneThis field is for validation purposes and should be left unchanged.Your Contact InformationWhich career path are you interested in pursuing?(Required)Select oneCertified Medical AssistantLicensed Practical NursePhysician AssistantMaster of Social WorkLicensed Mental Health CounselorYour Name(Required) First Middle Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your Email Address(Required) Enter Email Confirm Email Your Contact NumberHome PhoneMobile Phone(Required)Preferred Method of Contact Email Home Phone Mobile Phone Best Time to Call YouWhen is the best time for us to reach you via telephone?MorningEarly AfternoonLate AfternoonEarly Evening Education InformationThis field is hidden when viewing the formPrior Level of Education(Required)Prior education you have completed and for which you received a Diploma or Degree. Please check all that apply. GED High School Diploma Associate's Degree Bachelor's Degree Master's Degree Prior Highest Education Level Obtained(Required)Prior highest education level you obtained and for which you received a Diploma or Degree. GED High School Diploma Associate's Degree Bachelor's Degree Master's Degree Professional Licenses and CertificationsPlease list any professional licenses and certifications. Click on the + sign to add more rows. Add RemoveAre you currently enrolled in an education program?(Required) Yes No What is the name of your school?(Required)When does your program start and end?Start Semester(Required)SemesterFallSpringWinterSummerNot SureStart Year(Required)Year2024202520262027Expected Completion Month(Required)MonthJanFebMarAprMayJunJulAugSepOctNovDecNot sureExpected Completion Year(Required)Year202520262027Not sureDo you attend classes full-time or part-time?(Required) Full-time Part-time Do you attend classes in the day or evening?(Required) Day Evening Have you applied for financial aid?(Required) Yes No Type of Financial Aid(Required) FAFSA TAP Other What type of CMA program would you prefer?(Required) In-person Online Hybrid Which school are you considering?(Required)Select oneAdelphi UniversityBorough of Manhattan Community College (BMCC)CCNY Continuing and Professional StudiesHostos Community College, CUNYKingsborough Community CollegeLaGuardia Community CollegeLehman CollegeMonroe CollegeOrange County Community CollegeQueensborough Community CollegeStaten Island Community CollegeSuffolk County Community CollegeUlster County Community CollegeWestchester County Community CollegeOtherWhat is the name of the school?(Required)When would you like to begin your program?Preferred Start Semester(Required)Select oneAs soon as possibleSpringSummerFallWinterPreferred Start Year(Required)Select one202520262027CommentIs there anything else you would like to share regarding your education? Employment InformationThis field is hidden when viewing the formAre you a citizen of the U.S. or legally authorized to work in U.S.? (DEACT 062425)(Required) Yes No Are you legally authorized to work in U.S.?(Required) Yes No Are you a U.S. Citizen or Permanent Resident?(Required) Yes No Are you a New York State Resident?(Required) Yes No Are you currently employed?(Required) Yes No Is your current employment in healthcare?(Required) Yes No Are you working full-time or part-time?(Required) Full-time Part-time Employer Name(Required)Job Title(Required)Annual Salary(Required)Are you a union member?(Required) Yes No Please provide the name of your union:(Required)CommentIs there anything else you would like to share regarding your employment?Consent - Data Accuracy(Required)I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected. I agree(Required)Opt-InBy submitting this form and entering your email and phone number(s) above, you consent to be contacted by a representative from The Audacia Foundation, Inc. Opting-in is not a condition for your application to this program. You can opt-out at anytime by contacting us at support@audaciafoundation.org. I consent to be contacted by The Audacia Foundation, Inc.CAPTCHA
