MANDL SCHOOL ONLINE ENROLLMENT APPLICATION Thank you for your interest in Mandl School. Please fill in all fields below to the best of your ability and submit. You must complete your application in its entirety before you submit as you will not be able to save and return to the application. Once submitted, a Mandl School Admissions Representative will reach out to you shortly. Thank you! Step 1 of 3 - PERSONAL INFORMATION & PROGRAMS 0% PERSONAL INFORMATIONFirst Name*Last Name*Fill out Address in Spaces Below* Number and Street Name/Apt# City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone: Cell, Home or Work*Other Phone: Cell, Home or Work*Email* SOCIAL SECURITY #DATE OF BIRTH* MM DD YYYY GENDER*FEMALEMALENON-BINARYRACE & ETHNICITY*BLACK OR AFRICAN AMERICANHISPANICS OF ANY RACEWHITEASIANU.S. CITIZEN*YESNOPERMANENT U.S. RESIDENT*YESNOCITIZENSHIP OF ANOTHER COUNTRY*Name of country other than USA. If not applicable, please write NAI WISH TO ENTER MANDL FOR:*WINTER (January)SPRING (May)FALL (September)MY SCHEDULE CHOICE IS:* Select All DAY EVENING WEEKEND MANDL PROGRAMSPLEASE SELECT THE PROGRAM YOU WOULD LIKE TO PURSUE*Please check one program.A.O.S. IN MEDICAL ASSISTINGA.O.S. IN SURGICAL TECHNOLOGISTA.A.S. IN HEALTH CARE ADMINISTRATIONA.A.S. IN RESPIRATORY THERAPYA.A.S. IN DIAGNOSTIC MEDICAL SONOGRAPHY (DMS)A.A.S. IN HEALTH AND HUMAN SERVICESCERTIFICATE IN DENTAL ASSISTINGCERTIFICATE IN MEDICAL ASSISTING EDUCATIONAL BACKGROUNDHIGH SCHOOL, TRADE OR TECHNICAL SCHOOLS ATTENDED*Please list all High Schools and Trade or Technical Schools you have attended. Please tell us the: SCHOOL NAME / CITY & STATE / DATES ATTENDEDDO YOU HAVE A HIGH SCHOOL DIPLOMA OR G.E.D.*YESNOHIGH SCHOOL GRADUATION DATE*G.E.D. DATE (if not applicable, write NA)*COLLEGES ATTENDED*Please list all Colleges you have attended. Tell us the: COLLEGE & STATE / DATES ATTENDED / DEGREES EARNED. If not applicable, please write NA.EMPLOYMENT BACKGROUNDWORK EXPERIENCE: LIST LAST 3 EMPLOYERSList by: EMPLOYER & ADDRESS / POSITION / EMPLOYMENT DATES. If not applicable, write NA STUDENT REFERRALSSTUDENT REFERRALSPlease write down the name and phone # of friends or relatives who can benefit from an education at Mandl.ADDITIONAL INFORMATIONREFERENCESPlease provide two references who may be contacted by Mandl. Please write: NAME / ADDRESS / RELATION TO YOU / PH# / OCCUPATIONHOW DID YOU HEAR ABOUT MANDL?*INTERNETPRINT/TRANSITREFERRALSOCIAL (Facebook, Instagram, etc.)PLEASE READ*Although a credential/licensure is not required by the state, companies may make it a condition of employment, as well as conducting a criminal background check. An applicant should consider and personally evaluate whether or not there are personal circumstances or physical limitations that may adversely impact his or her ability to complete a program at Mandl.I HAVE READ THE ABOVE STATEMENTSTATEMENT OF UNDERSTANDING*I understand that this application cannot be processed if it has not been completed properly and that all information submitted is true to the best of my knowledge. Accordingly, any deliberate falsification or omission of data may result in a denial of admission or dismissal.I HAVE READ THE ABOVE STATEMENTTRANSCRIPT RELEASEPlease complete all lines below. By submitting this application for enrollment, I give permission for the High School named below to release a transcript of my grades to Mandl School - The College of Allied Health, at 254 West 54th Street, New York, NY 10019MY DATE OF BIRTH IS:*I ATTENDED YOUR HIGH SCHOOL*Write name of high school and addressI ATTENDED DURING THE YEAR(S):*MY NAME IS:*Please print, including maiden name if applicable.SOCIAL SECURITY #TRANSCRIPT RELEASE PERMISSION*I agree that the above information is accurate to the best of my ability and I give permission for Mandl School - The College of Allied Health to request a transcript of my grades from the High School listed above.I give my permissionI DO NOT give my permissionNon-Discrimination PolicyMandl School - The College of Allied Health does not discriminate on the basis of age, color, religion, creed, disability, marital status, veteran status, natural origin, race, gender or sexual orientation, in its educational programs, activities and employment.MANDL SCHOOL CATALOG AND STUDENT HANDBOOK*For disclosures and detailed program(s) information, please refer to the Mandl School Catalog & Mandl School Student Handbook located on our website and please confirm that you understand Mandl School has provided you with our School Catalog and Student Handbook.YES, I confirm that Mandl School has provided me with the ability to review the Mandl School Catalog and Student Handbook.NameThis field is for validation purposes and should be left unchanged.