Language
English (US)
Student Name:
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First Name
Middle Name
Last Name
Student Enrollment Form
Fill out the form carefully for enrollment
SSN:
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Example: 123-45-6789
Email Address:
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example@example.com
Gender:
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Male
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Address:
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Street Address
Street Address Line 2
City
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Mobile Number
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-
Area Code
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High School:
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Name of School
Diploma/GED:
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Yes
Year of Completion:
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Graduation/Completion Year
Emergency Contact
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First Name
Last Name
Emergency Contact Mobile Number
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Area Code
Phone Number
How did you hear about us?
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Course:
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Nursing Assistant 101
Course Options:
*
2 Week
6 Week-Classroom
6 Week-Hybrid (Blended Learning)
Start Date:
*
2/13-2/24/23-2 Week
3/13-3/24/23-2 Week
3/28-5/4/23-6 Week
4/3-4/14/23-2 Week
5/1-5/12/23-2 Week
Uniform Size:
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2X-Large
Have you ever been convicted of a crime?
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Have you received your COVID vaccination?
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Which vaccine did you receive?
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J&J
Moderna
Pfizer
Please list the date(s) of your vaccinations. Card will be required for enrollment.
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Security Deposit
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Enrollment Fee
$
155.93
Enrollment Fee is required to reserve your seat and is non-refundable. The remaining balance must be paid in full prior to taking the final exam. Failure to do so, will result in dismissal from the class. The $155.93 includes a $5.93 service fee and $150 will be applied to your balance.
Class
2 Week
6 Week
Total
$
0.00
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