World Outreach Medical Institute

World Outreach Medical Institute stands out as a school with a difference because of its small class sizes and the dedication of our instructors and staff. We are fully committed to the success of the individual student. Our commitment extends beyond the classroom. We offer placement assistance to our graduates. To help with the transition process from classroom to workforce we offer internship.

To be accepted for a specific program students can fill out an online application form and submit it or download and, complete an application and bring it to the office. Students may also schedule an appointment to visit the school by call 404-299-1271

APPLICATION FOR ADMISSION

Personal Data
SSN

Full Name

Address
City State Zip Code

Date of Birth

Telephone
Home ph# Work Cell/Pager

Email Address

Citizen Data
US Citizen? Yes No
Permanent Resident ? Yes No
How long have you been in the US?

Entrance Data
What do you plan to pursue? (check one)

Certified Nursing Assistant (CNA)
Patient Care Technician (includes Phlebotomy & EKG)
EKG/Phlebotomy
NCLEX RN/LPN Review
CPR
Medical Billing & Coding Specialist
Surgical Technician
Pharmacy Technician

Schedules:
Day (9am - 1:30pm)
Evenings (5pm-10pm)

Educational Data
Have you graduated from High School? Yes No If yes what year
If no, do you have a GED? Yes No If yes, what year
If no, state highest grade completed Name of last high school
Location of last high school
Is English your first language? Yes No
If no, have you taken English classes? Yes No

Have you been convicted of a crime? Yes No
If yes please describe what happened?

Note:Conviction of a crime will not preclude your admission.

Emergency Contact
Name Phone# Relationship
Name Phone# Relationship

I certify to the best of my knowledge that all the statements contained herein are correct and complete. I understand that discovery of a false statement are grounds for immediate dismissal and forfeiture of all financial payment and academic credits.

Applicant's Name Date

It is the policy of World Outreach Medical Institute that no person shall, on basis of race, color, religion, sex, national origin, age, disability, marital status, or sexual orientation, be excluded from participating in, be denied the benefits of, or be subjected to discrimination in any of its employment practices, educational programs services, or activities.

Admission
Remarks
WOMI Representative