Student Application
Campus
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Fort Myers, Florida
First Name
Middle Name
Last name
Cell Phone
Home Phone
Email
Home Address
Street
City
State/Province
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Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
Armed Forces
Armed Forces Americas
Armed Forces Pacific
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
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Kentucky
Louisiana
Maine
Manitoba
Marshall Islands
Maryland
Massachusetts
Michigan
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Mississippi
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Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
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Newfoundland
North Carolina
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Northern Mariana Islands
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
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Palau
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
N/A
Zip/Postcode
Country
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AFGHANISTAN
ALBANIA
ALGERIA
AMERICAN SAMOA
ANDORRA
ANGOLA
ANGUILLA
ANTIGUA AND BARBUDA
ARGENTINA
ARMENIA
ARUBA
AUSTRALIA
AUSTRIA
AZERBAIJAN
BAHAMAS
BAHRAIN
BANGLADESH
BARBADOS
BELARUS
BELGIUM
BELIZE
BENIN
BERMUDA
BHUTAN
BOLIVIA
BOSNIA AND HERZEGOVINA
BOTSWANA
BRAZIL
BRITISH VIRGIN ISLANDS
BRUNEI
BULGARIA
BURKINA FASO
BURUNDI
CAMBODIA
CAMEROON
CANADA
CAPE VERDE
CAYMAN ISLANDS
CENTRAL AFRICAN REPUBLIC
CHAD
CHILE
CHINA
COLOMBIA
COMOROS
CONGO, DEMOCRATIC REPUBLIC OF THE
CONGO, REPUBLIC OF THE
COOK ISLANDS
COSTA RICA
CROATIA
CUBA
CYPRUS
CZECH REPUBLIC
DENMARK
DJIBOUTI
DOMINICA
DOMINICAN REPUBLIC
EAST TIMOR
ECUADOR
EGYPT
EL SALVADOR
EQUATORIAL GUINEA
ERITREA
ESTONIA
ETHIOPIA
FAROE ISLANDS
FIJI
FINLAND
FRANCE
FRENCH GUIANA
FRENCH POLYNESIA
GABON
GAMBIA
GEORGIA
GERMANY
GHANA
GIBRALTAR
GREECE
GREENLAND
GRENADA
GUADELOUPE
GUAM
GUATEMALA
GUINEA
GUINEA-BISSAU
GUYANA
HAITI
HONDURAS
HONG KONG
HUNGARY
ICELAND
INDIA
INDONESIA
IRAN
IRAQ
IRELAND
ISRAEL
ITALY
IVORY COAST
JAMAICA
JAPAN
JORDAN
KAZAKHSTAN
KENYA
KIRIBATI
KOSOVO
KUWAIT
KYRGYZSTAN
LAOS
LATVIA
LEBANON
LESOTHO
LIBERIA
LIBYA
LIECHTENSTEIN
LITHUANIA
LUXEMBOURG
MACAO
MACEDONIA
MADAGASCAR
MALAYSIA
MALAWI
MALDIVES
MALI
MALTA
MARSHALL ISLANDS
MAURITANIA
MARTINIQUE
MAURITIUS
MEXICO
MICRONESIA, FEDERATED STATES OF
MOLDOVA
MONACO
MONGOLIA
MONTENEGRO
MONTSERRAT
MOROCCO
MOZAMBIQUE
MYANMAR
NAMIBIA
NAURU
NEPAL
NETHERLANDS
NETHERLANDS ANTILLES
NEW ZEALAND
NICARAGUA
NIGER
NIGERIA
NORTH KOREA
NORTHERN MARIANA ISLANDS
NORWAY
OMAN
PAKISTAN
PALAU
PALESTINE
PANAMA
PAPUA NEW GUINEA
PARAGUAY
PERU
PHILIPPINES, REPUBLIC OF
POLAND
PORTUGAL
PUERTO RICO
QATAR
ROMANIA
RUSSIAN FEDERATION
RWANDA
SAINT KITTS AND NEVIS
SAINT LUCIA
SAINT VINCENT AND THE GRENDINES
SAMOA
SAN MARINO
SAO TOME AND PRINCIPE
SAUDI ARABIA
SENEGAL
SERBIA AND MONTENEGRO
SEYCHELLES
SIERRA LEONE
SINGAPORE
SLOVAKIA
SLOVENIA
SOLOMON ISLANDS
SOMALIA
SOUTH AFRICA
SOUTH KOREA
SPAIN
SRI LANKA
SUDAN
SUDAN, SOUTH
SURINAME
SWAZILAND
SWEDEN
SWITZERLAND
SYRIA
TAIWAN
TAJIKISTAN
TANZANIA, UNITED REPUBLIC OF
THAILAND
TOGO
TONGA
TRINIDAD AND TOBAGO
TUNISIA
TURKEY
TURKMENISTAN
TUVALU
TURKS AND CAICOS ISLANDS
UGANDA
UKRAINE
UNITED ARAB EMIRATES
UNITED KINGDOM
UNITED STATES OF AMERICA
URUGUAY
UZBEKISTAN
VANUATU
VATICAN CITY
VENEZUELA
VIETNAM
VIRGIN ISLANDS, U.S.
YEMEN ARAB REPUBLIC
ZAMBIA
ZIMBABWE
Birth Date
Social Security No
Gender
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Male
Female
Ethnicity
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AMIND
OTHER
White/Caucasian
Hispanic or Latino
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
Two or more races
Unknown
PISLD
TWMOR
White
BLACK
Marital Status
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Single
Married
Divorced
Widowed
Separated
Driver’s License #:
DL State of Issue:
Emergency Contact
Contact Name
Address
Cell Phone
Home Phone
Work Phone
Highest Education Level
(please check all that apply)
Highest Level of Education
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Advanced Degree
Associates Degree
College Grad - Baccalaureate
G.E.D.
High School Grad- Diploma
High School Grad- Transcript
High School Student
Some post secondary
HS Graduation Date
How did you hear about us?
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Walk In
Radio
Friend
Internet
Newspaper
Job Fair
Fire/EMS Department
High School Career Fair
Other
If Other, please specify
Military
Have you ever served in the armed forces
Yes
No
Not Selected
Are you a Disabled Veteran
Yes
No
Not Selected
Did you submit a copy of your DD214
Yes
No
Not Selected
Did you submit a copy of Certificate of Eligibility
Yes
No
Not Selected
Learning Disability
(must attach doctors note)
Do you have or have been diagnosed with a learning disability:
Yes
No
Not Selected
Doctors Note
Do you require any special accommodations for a disability:
Yes
No
Not Selected
If you yes to any of the above can you provide medical documentation of the disability
Yes
No
Not Selected
Select Program
Enroll In
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Spring 2025
Summer 2025
Fall/Winter 2025
Program
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Associate of Science in Emergency Medical Services (EMS)
Associate of Science in Fire Science Technology (FST)
Associates of Science, in Nursing (ASN)
Bachelor of Science, in Healthcare Administration (HA)
Bachelor of Science, in Nursing (BSN)
Bachelor of Science, in Public Administration (PA)
Emergency Medical Technician- Day (EMT-D)
Emergency Medical technician- Night (EMT-N)
Firefighter I & II (FIREFIGHTER I & II)
Paramedic (PARAMEDIC)
Program Schedule
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Day
Night
Hybrid
New Student:
Yes
No
Not Selected
Transfer Student
Yes
No
Not Selected
Are credits being transferred in:
Yes
No
Not Selected
Did you attend courses at Braxton College:
Yes
No
Not Selected
If yes which class:
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EMT
Fire
Paramedic
Are you currently enrolled in a program at Braxton College
Yes
No
Not Selected
If Yes, which program:
Associates of Science, in Emergency Medical Services
Associates of Science, in Fire Science Technology
Bachelor of Science, in Public Administration
Bachelor of Science, in Healthcare Administration
Bachelor of Science, in Nursing
EMT
Firefighter I & II
Paramedic
Admissions Documents (please upload a PDF FIle only. No pictures)
Copy of Drivers License
Social Security Card
High School Diploma, High School Completion, GED or equivalency
Student Signature:
Please read before submitting application: By signing your name, you hereby acknowledge that the $100.00 Program Registration fee is nonrefundable. You agree to provide Braxton College with official High School transcripts or copy of High School diploma, College or University transcripts and all admission requirements prior to the course beginning.
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