Medical Career Institute

Education High School Information: □ High School □ GED □ Equivalent Diploma Name of High School Attended: Year of High School Graduation: ______Medical Career Institute 27975 Old 41 Road, Suite 201 PLEASE PICK ONE OF THE ITEMS BELOW Bonita Springs, Fl 34135 High School Graduate Only Some College Associates Degree Office: (239) 992-4MCI □ □ □ Fax: (239) 405-8024 Military Student Application Have you ever served in the armed forces: YES/NO Are you a Disabled Veteran: YES/NO Disability Please Print Clearly Do you have or have been diagnosed with a learning disability: YES/NO Registration fee $100.00 Do you require any special accommodations for a disability: YES/NO First Name: If you yes to any of the above can you provide medical documentation of the disability: YES/NO

Home Phone: How did you hear about us? E-Mail Address: □ Friend □Internet □Radio □ Newspaper □ Job Fair □ High School Flyer □ Department Flyer □ Other: ______

Home Address Courses Interested In Street: (Check all that Apply)

Apartment #: □ EMT □ Paramedic □ FF II & II □ ACLS □ PALS □ ITLS □

City: Registration Course Deadline State: Zip Code: EMT □ Lee County B Shift, except weekends □ Tues, Thurs night and Saturday day Date of Birth: □ Online/Hybrid Class Paramedic Driver’s License #: □ B Shift □ Tuesday Only □ Wednesday Only Race: □ Online/Hybrid Firefighter I & II Sex: □ Monday/Wednesday & Friday Nights 1-2 Sundays per month AS Degree □ Emergency Medical Services Emergency Contact □ Fire Science Technology Name: ______

Relation: ______Address: ______

______

Phone #:______

Student Shirt Size: ______Student Signature: Date: Administrator Only Admission Date: Admission Rep: ______

Did student supply Disability Forms: YES/NO Are they attached: