Admission Form

Admission Form

Ensuring the security and protection of your personal information is important to us. All information submitted to us are transmitted securely with a 256 bit High-grade encryption. If you do not wish to use our online form, you have the option to submit the documents in-person at the Registrar's Office.
Personal Information
Email Address *
please use same e-mail address on all forms
Full Legal Name *

First Name Middle Name Last Name
Preferred First Name
Other names you may have used
I am interested in: (select all that apply) *

Basic Nurse Assistant Pharmacy Technician Dialysis Technician Restorative Nurse Assistant EKG Technician Phlebotomy Technician Patient Care Technician Physical Therapy/OT Assistant Electronic Health Record Specialist
Home/Permanent Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Primary Phone No. *

Area Code Phone Number
Alternate/Cellphone No.

Area Code Phone Number
Valid Social Security No.
Please omit dashes (-).
Birth Date *

Month Day Year
Sex *

Male Female
Citizenship *

US Citizen US Permanent Resident Neither US Citizen nor Permanent Resident
Country of Citizenship *
If you were not born in US but now live here, how long have you lived in the US?
Ethnic Background for US Citizen and US Permanent Residents (Please check all that apply) *

Black/African American Mexican American/Chicano White Native Hawaiian American Indian/Alaskan Native Asian American/Pacific Islander Other Hispanic/Latino Other Decline to State
Educational Background
Grade School
Name of School *
Year Attended *
High School
Name of School *
Year Attended *
College
Name of School
Year Attended
Certificate
Name of School
Year Attended
Family Information
Full Name
Relationship *
Occupation
Employer
Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Applicant's Pledge
By submitting this supplement,

-   I affirm that all the information contained in this form is factual and complete to the best of my knowledge.

-   I understand that I have to pay $25.00 after submission of this form.

-   I understand that this Registration is only valid for one year and if I did not proceed with the enrollment before expiration date, I will have to pay another registration fee and I will have to re-register.
Applicant's Full Name *
Date Submitted *

Month Day Year
Signature
Enter the message as it's shown *
By clicking submit, you will also be added to Jethro Healthcare School mailing list. You will receive promotions, school announcements and Newsletter from Jethro Healthcare School

weekly or bi-weekly in the supplied e-mail. If, at any time, you wish to be removed from our mailing list, you may follow the removal instructions included in each e-mail or Newsletter issue.
Should be Empty:

Admission Form

Personal Information

Educational Background

Family Information

Applicant's Pledge