LPN/Lab/Imaging Application All fields are required. Please use none or zero where appropriate. Please note, if you are not a CAMC employee, you may skip the CAMC Employment information and move on to the College Enrolled section. You must be accepted and enrolled in an accredited Career and Technical Center or College/University in order to be considered for this program. Anyone beginning first semester must provide your program acceptance letter on school letterhead in order to be considered. If you are a returning student in a second or later semester, please provide your most recent unofficial transcript which must include your name, the school name, semester and year, classes and grades, and current and cumulative grade point average. The application deadline date for spring 2022 semester is November 1, 2021. For any additional assistance, use this form Ask a question


Personal Last Name
Last Name is Required Last Name can only be 100 characters long

First Name
First Name is Required First Name can only be 100 characters long

Middle Initial
Middle Initial is Required Middle Initial can only be 50 characters long

Street Address
Street Address is Required can only be 200 characters long

City
City is Required can only be 50 characters long

State
State is Required can only be 50 characters long

Zip
Zip is Required Zip has to be 5 digit number

County Of Residence
County Of Residence is Required can only be 100 characters long

Email
Email is Required Email can only be 100 characters long Email is not in valid format name@domain.xxx

Home/Cell Phone
Home Phone is Required Home phone number is not in correct format. Use one of these: xxx-xxx-xxxx | xxx-xxxx | x-xxxx

Work Phone
Work Phone is Required Work phone number is not in correct format. Use one of these: xxx-xxx-xxxx | xxx-xxxx | x-xxxx

Employement Are you a CAMC Employee?

Yes

No

CAMC Employee is Required

Education College Enrolled
College Enrolled is Required College Enrolled can only be 200 characters long

School Street Address
School Street Address is Required School Street Address can only be 200 characters long

School City
City is Required City can only be 50 characters long

School State
State is Required State can only be 50 characters long

School Zip
Zip is Required Zip has to be a 5 digit number

Student ID
Student ID is Required Student ID can only be 50 characters long

Major
Major is Required Major can only be 100 characters long

Semester enrolled in nursing school Please provide your nursing acceptance letter by emailing brianna.chin@camc.org. Letter must be on college letterhead and signed.

If you are a returning student in a second or later semester, please provide your most recent unofficial transcript which must include your name, the school name, semester and year, classes and grades, and current and cumulative grade point average.

1st 2nd 3rd 4th 5th 6th 7th 8th Last N/A
Major is Required

Associate Degree
Associate Degree is Required Associate Degree can only be 100 characters long

Bachelor Degree
Bachelor Degree is Required Bachelor Degree can only be 100 characters long

Anticipated Graduation Date
Anticipated Graduation Date is Required Date is not in proper format or is out of range. Please use format MM/DD/YYYY

Have You Completed FAFSA

Yes

No

FAFSA is Required