FIRST AND LAST NAME

EMAIL

PHONE NUMBER

STREET ADDRESS

CITY

STATE

ZIP CODE

DATE OF BIRTH

GENDER GENDER MALE FEMALE

RACE RACE White/Caucasian Black or African American American Indian or Alaska Native Hispanic Asian Other

This application is for enrollment as: Do you have a High School Diploma This application is for enrollment as: Do you have a High School Diploma Cosmetology Program Esthetician Program (Make-up & Skin) Nail Program Barbering