Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.First Name *Middle *Last Name *Sex *MaleFemalePrimary Address *City *StateZip *Primary E-mail Address *Driver’s License # *Marital Status: *Select OneSingleMarriedSeparatedDivorcedWidowedU. S. Citizen: *Select OneYesNoIf NO, Alien No. *Birthplace (City, State/Country) *Primary Address *City *State Zip *Employer Name *Please select last grade completed9101112High School NameGraduated *Select OneYesNoGED School NameCollege NameCourse/s StudiedGraduatedSelect OneYesNoHave you ever been convicted of a felony or currently awaiting trial on felony charges? *Select OneYesNoIf yes, explain *Are you on probation or parole? *Select OneYesNoIf yes, explain in detail including name and telephone number of probation officer *Parent/s-Guardian/s Full NameNameNameEmergency Contact (Name and Ph#)RelationshipDo you have any physical impairment which might affect your training at La Dolce Vita Cosmetology Institute?Select OneYesNoHearing Loss?Select OneYesNoPercentage & SideHeart Condition?Select OneYesNoSight Loss?Select OneYesNoPercentage & SideHernia?Select OneYesNoColor Blindness?Select OneYesNoTuberculosis?Select OneYesNoNervous Disorders?Select OneYesNoDiabetes?Select OneYesNoConvulsions?Select OneYesNoOther (explain)Are you presently under a doctor’s care for a physical problem?Select OneYesNoAre you presently under a doctor’s care for an emotional problem?Select OneYesNoDo you take any, including prescribed medication for the following?Select OneDiabetesEpilepsyCardiac ConditionHypertensionAsthma/Hay FeverDo you have a sight or coordination problem that limits your mobility? Yes____ No____ Do you have an impairment that causes you to walk with difficulty or Confines you to a wheelchair?Select OneYesNoHow did you learn about La Dolce Vita Cosmetology Institute? Check all that applyHigh School CounselorEmployerCareer DayFamily MemberNewspaper AdRadioYellow PagesFriend/AcquaintanceInternetMagazine AdTelevisionSalon/SpaOtherWho (other than you) most influenced you in your final decision to enroll at La Dolce Vita Cosmetology Institute?CosmetologyI wish to apply for admission for the month of June 16, 2025Cosmetology InstructorTransfer Students: Previous training at (School name and address), and Total Hours completedProceed To Payment
