Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you applied to RSP before? *

Yes

No

Date of Birth *

MM

DD

YYYY

Are you able to work in the U.S? *

Yes

No

Have you served in the military/ armed services? *

Yes

No

Are you associated with WorkSource or another source assisting with funding of tuition? *

Yes

No

If you are eligible for government assistance (TANF, SNAP) you may qualify for tuition assistance. Are you interested in learning more?

Yes

No

Ae you currently employed in a healthcare facility? *

Yes

No

Emergency Contact *

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Primary Education *

High School

GED

Postsecondary Education *

No college

Some college

Program Certificate

Apprenticeship

Associate Degree

Bachelor Degree

Master Degree

Doctorate or Professional Degree

Employment *

Are you currently employed?

No

Yes, less than 30 hours/week

Yes, 40+ hours/ week

Retired

Medical Leave

Classes are scheduled 4 days, 4 hours each day and based on Student and Instructor availability. If choosing an internship, this will be scheduled after these 4 classes are complete. *

I understand

Yes

No

After submitting this applciation, you will be scheduled for a placement test. This is how the program evaluates what you will need to focus on during your class time. *

I understand

Yes

No

There is a non-refundable $45 application fee required when submitting this application *

How will this be paid ?

In person at my enrollment or placement test (cash or check only)

I need an invoice sent to my email so I can pay online

My WorkSource coach, EQUUS, PY+, employer, or other financial aid partner will pay

Students must comply with RSP Student Code of Conduct Policies including, but not limited to Attendance, Behavior, and Drug Testing Policies. This is relivant during didactic and internship parts of the program. *

I understand

Yes

No

You will be required to submit with this application: Your photo ID, proof of High School Graduation or equivalency, and your resume. These can be submitted to ajones@roguesp.org *

I understand

Yes

No