= required field

Personal Information

First Name

Last Name

Address

City

State
Choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
ZIP

Home Phone

Work Phone

Cell Phone

Cell Phone Carrier
Select Alltel AT&T Boost Mobile Chat Mobility Cricket I Wireless Long Lines Metro PCS Nextel Qwest Wireless Sprint Straight Talk T-Mobile US Cellular Verizon Viaero Virgin Mobile Other
E-mail

Birthdate
Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Birthplace

Maiden Name

Are You Employed?
Select Yes No
Marital Status
Select Single Married Divorced Widowed
Children?
Select Yes No

Parent or Guardian

Name

Relationship

Address

City

State
Choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
ZIP

Phone

Emergency Contact

In case of emergency, indicate the person
you wish USCA to contact.

Name

Relationship

Phone

Education

Education Completed:

High School
GED
Some College
Associates Degree (2 year)
Bachelors Degree (4 year)
Vocational School
Other (please specify)

High School

Year Graduated

Diploma GED

From Month January February March April May June July August September October November December to Month January February March April May June July August September October November December

Have you attended any colleges/universities,
cosmetology schools or post-secondary
training (college level)?

Select Yes No

If yes, where and when?

If yes, did you complete? If not, why not?

Course of Study

Which course would you like to enroll in?

Select Cosmetology Esthiology Nail Technology Massage Therapy for the Professional Teacher Training

Select date of enrollment & schedule*

* Dates in parentheses represent class start dates
for Esthiology & Full Time Nail Technology.

How did you hear about USCA?

Current Student
Name:
Graduate Student
Name:
Salon/Stylist
Name:
Radio
Station:
Newspaper
Name:
Internet - Beauty Schools Directory
Internet - USCA Web Site
Other
Please specify:

Financial Information

How do you plan to pay your tuition?

If other, please explain:

Have you previously used any Federal Financial Aid?
Select Yes No

Confidential Success Questionnaire

What is the primary reason that you
have chosen this career and this school?

List any limitations that may affect your
your ability to succeed at our school.

Have you ever been convicted of a felony?

How will you support yourself financially
while you are in school?

What kind of work or employment do you have at
this time and will you continue during school?

Have you made child care arrangements?

Do you have reliable transportation to school?

What are your plans for employment
when you complete your program?

Final Review

Once you are certain all required entries
are complete, please read the following:

I understand that this is an application for enrollment, not a
contract. All information I have provided is true and complete.

An application fee of $50 is due prior to the class date
and is non-refundable.

Note:
Massage Therapy students do not have a $50 application fee.

I understand and agree to the above statements.

Enter the Security Code As Shown