HomeEducationAdult Education10-month LPN ProgramLPN Program EnrollmentLicensed Practical Nursing (LPN) Program Application Licensed Practical Nursing (LPN) Program Application LPN Application. Step 1 of 4 25% Student InformationSelect the location you wish to attend.(Required) Belmont Olean Select the CTE Center you wish to attend.Student Name(Required) First Middle Last Enter your first, middle, and last name.Work Phone(Required)Enter your work phone number.Primary Phone(Required)Enter your primary phone number.Email(Required) Enter your most used email address.Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Enter your birthday in the mm/dd/yyyy format.Gender(Required) Male Female Please note that the data we report each year only allows us to report two genders.Martial Status(Required) Single Married Enter your martial status as of completing this form.High School Graduate or Equivalent (GED Test, etc.)?(Required) Yes No Please select "Yes" if you have a HS diploma, GED or equivalent. Select "No" otherwise.Year Graduated Enter the year you graduated from the high school you attended or completed your GED test, if applicable.High School Graduated From Enter the high school you graduated from or attended, if applicable.Student Information 2Social Security Number Optionally, please enter your social security number.Mailing Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Enter your mailing address.Emergency Contact(Required) First Last Enter your emergency contact by first and last name.Emergency Contact Phone(Required)Enter your emergency contact's primary phone number.Emergency Contact Relationship(Required) Spouse Mother Father Friend Relative (aunt, uncle, cousin, etc) Other Please specify the relationship with your emergency contact. Demographic InformationRace(Required) Hispanic/Latino Black or African American Native Hawaiian or Pacific Islander Asian Native American Multi-Racial White Please indicate your race(s).Employment StatusPlease check all that apply. Employed Currently Full Time Employed Currently Part Time Unemployed Currently Not in Labor Force; i.e. retired Receiving Unemployment Ins. Economic StatusPlease check all that apply. Receiving Public Assistance Receiving HEAP or WIC Receiving SSI Economically Disadvantaged Single Parent Disability StatusPlease check all that apply. Learning Disability Veteran Handicapped Dislocated Worker Limited English Funding Source(s)(Required) Self Employer Seneca Nation Indians One Stop - Catt County ACCESS - VR Emp. & Training (All. Co.) Please check all that apply.CABOCES Adult Education & Workforce Development can qualify for funding from the New York State Department of Education if we serve enough economically disadvantaged students. In our experience, most of our students are not aware that they qualify because they do not know the way it is figured out. You will need to know the following information to answer the following question: The number of people whose permanent address is your residence; and your gross income, either for the year or by paycheck. Are you economically disadvantaged?(Required)Please look at the table on the left to determine. Yes No Application EssayApplication Essay(Required)In the space below, please discuss in a short paragraph your reasons for applying to our LPN program. Student Name (Printed)Please print your full name below. Student Signature(Required)Sign this form with your signature below.Date SignedMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please enter the date you completed this form in the mm/dd/yyyy format.NOTE: YOUR APPLICATION FOR LPN IS NOT CONISDERED COMPLETE UNTIL WE HAVE RECEIVED TRANSCRIPTS PROVING YOU GRAUDATED FROM HIGH SCHOOL OR OBTAINED THE EQUIVALENT. PLEASE CONTACT US IF YOU HAVE ANY QUESTIONS.Notice of Non-Discrimination The Cattaraugus-Allegany-Erie-Wyoming Board of Cooperative Educational Services does not discriminate on the basis of an individual’s actual or perceived race, color, religion, creed, ethnicity, national origin, citizenship; status, age, marital status, partnership status, disability, predisposing genetic characteristics, sexual orientation, gender (sex), military status, veteran status, domestic violence victim status or political identity, gender expression, and religious practices or any other basis prohibited by New York State and/or federal non-discrimination laws in employment or its programs and activities. The District provides equal access to community and youth organizations. Inquiries regarding the District’s non-discrimination policies should be directed to: Civil Rights Compliance Officer, Human Resources, Cattaraugus-Allegany BOCES, 1825 Windfall Road, Olean, NY 14760, 716-376-8237. Email: CivilRightsCompliance@caboces.orgcreate new email NameThis field is for validation purposes and should be left unchanged. Δ