Step 1 of 3 33% Your Contact InformationWhich career path are you interested in pursuing?(Required)Select oneCertified Medical Assistant (CMA)Licensed Practical Nurse (LPN)Physician Assistant (PA)Master of Social Work (MSW)Licensed Mental Health Counselor (LMHC)Your 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?MorningsEarly AfternoonLate AfternoonEarly Evening Education InformationPrior 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 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)Program Start Date(Required)Example: Fall 2024, Spring 2025, Etc.Expected Completion Month(Required)MonthJanFebMarAprMayJunJulAugSepOctNovDecNot sureExpected Completion Year(Required)Year202520262027Not sureDo you attend classes full-time or part-time? Full-time Part-Time Do you attend classes in the day or evening? Day Evening Have you applied for financial aid?(Required) Yes No Type of Financial Aid(Required) FASFA TAP Other CommentIs there anything else you would like to share regarding your education? Employment InformationAre you a citizen of the U.S. or legally authorized to work in U.S.?(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? Full-time Part-Time 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.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
