STEIN ACADEMY
Application for Admissions
600 Reisterstown Rd. Baltimore, MD 21208; Tel: 410-602-0666
Certificate Program you are applying:
Certified Nursing Assistant Beginning: Time:
Phlebotomy Technician Beginning: Time:
Pharmacy Technician Beginning: Time:
Nurse Tech/Patient Care Tech Beginning: Time:
EKG Technician Beginning: Time:
ETC, ETC.
1. Name:
 
(Last)
(First)
(Middle)
(Maiden)
2. Home Address:
 
(Street)
(City)
(State)
(Zip)
3. Telephone #: () Alternate Telephone #: ()
4. E-mail Address:
5. Birth date: (Age): Sex: Male: Female:
 
(Month)
(Day)
(Year)
6. High School Graduate Of:
 
(School) or (GED)
(State)
(Year)
7. Religious Preference (optional): Marital Status: Married Single
8. Social Security Number U.S. Citizen? Yes: No: If not Visa type:
Financial Aid cannot be processed without Social Security number.
9. Permanent Resident:
 
(County)
(State)
(Zip)
10. Ethnic/Racial Status (required for federal and state accounting purposes only):
Asian/American Black/American Mexican/American
White American Indian Hispanic/American Other
11. Have You Earned Previous College Credit? Yes: No: Hours of Credit:
Name of College Where Credit Was Earned
13. Have You Ever Been Convicted of a Felony? Yes: No: If yes, please note,
depending on the program, that you may be denied participation in clinical or externship. You may also be denied Certification or registration by some professional boards. You may also be denied employment by some employers.

** Also note that you may face similar problems as just stated above for felonies if you have a positive drug test result.

14. How did you find out about Stein Academy? (Please check)
TV Radio Internet/web Friend/Co-worker Former Student Banner in front of school
From US Higher Education website Form Workforce Development The Baltimore Sun
Employment Guide PennySaver Other Source. Please list:
PARENT/GUARDIAN INFORMATION (for minors and applicants under 18 years)
1. Parent/GuardianName:
 
(Last)
(First)
(Middle)
2. Home Address:
 
(Street)
(City)
(State)
(Zip)
3. Home Phone #: () Work Phone #: () Cell Phone #: ()
4. Primary E-mail: Secondary E-mail:

All Entering Students Are Required To Submit, in addition to other admission requirements, a copy of a photo ID and a copy of their High School Certificate or GED and a copy of their Social Security Card.

Attendance is required at the first class meeting. Students who do not attend the first meeting of each class in which they are registered may be dropped from the class.

FOR FURTHER INFORMATION, contact: Admissions: (410) 602-0666

I certify that the information given is correct and complete. I understand that submission of false information is grounds for denial of admission, re-enrollment or immediate suspension if enrolled. If accepted as a student at Stein Academy, I agree to abide by the rules and regulations of the college regarding conduct, financial and other obligations. By signing this statement, I also hereby authorize the release of my drug screening results and other pertinent records to Stein Academy.

Students under 18 years of age and employer requirements: Please note that employer requirements and/or federal and state laws vary and may adversely affect your employment. In other words, students who are under the age of 18 may be denied employment after graduation and/or participation in certain externship or internship programs as a result of their age. They may also be denied certification or registration with certain professional boards. The student should consider these realities and discuss it carefully with their parents or guardians before registering for any of our programs.