Application - Mentee College

How to Apply

Applying for our programs is a straightforward process. Just follow these simple steps:

Select the degree type from the dropdown menu below (Certificate, Associates, or Diploma)

For Certificate programs (Nurse Aide/CNA, Medical Assistant), choose "Certificate" - Application fee is $35

For the Practical Nursing (LPN) program, choose "Diploma" - Application fee is $75

For Medical Assistant Associates, choose "Associates" - Application fee is $75

Fill out the form completely with your details
Pay the application fee at the bottom - your application is submitted once payment is complete!

Questions? Contact us at 770-931-5020

Choose Application Type:

Program Selection

Certificate Program *

Start Date *

Schedule Preference *

Day Classes Evening/Night Classes Weekend Classes

Personal Information

Please print clearly

First Name *

Last Name *

M.I.

Street Address *

Apt. #

City *

State *

ZIP Code *

Home Phone

Cell Phone *

Email *

Social Security Number *

Your SSN is used for verification only and is NOT stored in our database.

Date of Birth *

Gender *

How did you hear about us? *

Emergency Contact Information

First Name *

Last Name *

Relationship *

Cell Phone *

Educational/Professional Background

Highest Level of Education Completed *

Previous/Current Medical Skills and/or Experience(s)

High School Attestation

(If unable to present copy of diploma/GED, please complete this section)

I am unable to present an official copy of my high school diploma and/or GED at this time

Interest & Medical Disclosure

Please state your reason and/or interest in this program *

Are there any medical diagnoses and/or disabilities that would prohibit your program requirements? *

(e.g., diabetes, high blood pressure, back pain)

No Yes

Photo, Video and Review Release

I grant Mentee College, their affiliates, legal representatives and assigns, and those acting with their authority and permission the irrevocable and unrestricted right and permission to create, use, re-use, publish and re-publish photographic or video portraits or pictures of my likeness in connection with any publication or materials relating to Mentee College, including advertisements, marketing, publicity, brochures, web and digital media or other promotional materials.

I also grant Mentee College the right to use any written or recorded reviews, testimonials, or statements I provide in connection with marketing or promotion of Mentee College's programs.

Please select one: *

I am 18+ years old and give my consent I am under 18 and my parent/guardian consents I do NOT give my consent

Declaration & Signature

I DECLARE THAT ALL THE ABOVE STATEMENTS ARE TRUE AND THAT ANY MISREPRESENTATION AND/OR OMISSION ARE CAUSE FOR DISMISSAL/TERMINATION FROM MENTEE COLLEGE AND I ASSUME ALL LIABILITY AND PENALTIES.

I have read and agree to the above declaration *

Signature (Type Full Name) *

Date *

Application Fee

Application Fee: $35.00

Nonrefundable/Nontransferable

Your application will be considered complete upon receipt of the application fee.

Program Selection

Associates Program *

Semester *

Personal Data

First Name *

M.I.

Last Name *

Address *

Date of Birth *

SSN *

Your SSN is NOT stored - used for verification only.

Phone Number *

Email *

Gender *

Marital Status *

Single Married Widowed Divorced

Do you have dependent children at home? *

Yes No

How did you hear about us?

Emergency Contact Person

First Name *

Last Name *

Phone Number *

Educational Data

High School Graduate? *

Yes No

GED/HSE? *

Yes No

Colleges Attended

Professional Experience / Employment History

Start with current job and note any health care experience

Legal Disclosure

Have you ever been convicted of anything other than a moving traffic violation? *

Yes No

Terms & Acknowledgments

By submitting this application, I understand:

Acceptance into the program is not guaranteed
If not accepted, I must reapply for the following year
It is my responsibility to submit all required documents
If accepted, I must attend mandatory program orientation
If accepted, I must submit proof of required certifications and health documents

Signature (Type Full Name) *

Date *

I certify that the information given above is correct and complete.

Application Fee

Application Fee: $75.00

Your application will be considered complete upon receipt of the application fee.

Program Selection

Diploma Program *

Semester *

Personal Data

First Name *

M.I.

Last Name *

Address *

Date of Birth *

SSN *

Your SSN is NOT stored - used for verification only.

Phone Number *

Email *

Gender *

Marital Status *

Single Married Widowed Divorced

Do you have dependent children at home? *

Yes No

How did you hear about us?

Emergency Contact Person

First Name *

Last Name *

Phone Number *

Educational Data

High School Graduate? *

Yes No

GED/HSE? *

Yes No

Colleges Attended

Prerequisite Courses (LPN Program)

Course Name	College/University	Year	Semester	Grade
ALHS 1090 - Medical Terminology
BIOL 1011 - Anatomy and Physiology
BIOL 1011L - Anatomy and Physiology Lab
ENGL 1101 - Composition and Rhetoric
MATH 1111 - College Algebra
PSYC 1101 - Introductory Psychology
SPCH 1101 - Public Speaking

Entrance Examination

Date Taken

Certified Nurse Aide Requirement

Year Completed

License #

Expiration Date

Professional Experience / Employment History

Start with current job and note any health care experience

Legal Disclosure

Have you ever been convicted of anything other than a moving traffic violation? *

Yes No

Terms & Acknowledgments

By submitting this application, I understand:

Acceptance into the program is not guaranteed
If not accepted, I must reapply for the following year
It is my responsibility to submit all required documents
If accepted, I must attend mandatory program orientation
If accepted, I must submit proof of required certifications and health documents

Signature (Type Full Name) *

Date *

I certify that the information given above is correct and complete.

Application Fee

Application Fee: $75.00

Your application will be considered complete upon receipt of the application fee.

Program Application

How to Apply

Program Selection

Personal Information

Emergency Contact Information

Educational/Professional Background

High School Attestation

Interest & Medical Disclosure

Photo, Video and Review Release

Declaration & Signature

Application Fee

Program Selection

Personal Data

Emergency Contact Person

Educational Data

Colleges Attended

Professional Experience / Employment History

Legal Disclosure

Terms & Acknowledgments

Application Fee

Program Selection

Personal Data

Emergency Contact Person

Educational Data

Colleges Attended

Prerequisite Courses (LPN Program)

Certified Nurse Aide Requirement

Professional Experience / Employment History

Legal Disclosure

Terms & Acknowledgments

Application Fee