Language
English (US)
Student Enrollment Form
Fill out the form carefully for enrollment
Student Name:
*
First Name
Middle Name
Last Name
SSN:
*
Example: 123-45-6789
Email Address:
*
example@example.com
Gender:
*
Male
Female
N/A
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number
*
-
Area Code
Phone Number
High School:
*
Name of School
Diploma/GED:
*
Yes
Year of Completion:
*
Graduation/Completion Year
How did you hear about us?
*
Emergency Contact
*
First Name
Last Name
Emergency Contact Mobile Number
*
-
Area Code
Phone Number
Course:
*
Nursing Assistant 101
Phlebotomy 101
Course Options:
*
CNA
2 Week
Phlebotomy
6 Week (Hybrid-Classwork Online/Skills Lab in person)
Start Date:
*
CNA Classes- 2 Week
12/4-12/15/23
Phlebotomy Classes
TBA
Have you ever been convicted of a crime?
*
Yes
No
If so, please explain:
Uniform Size:
*
X-Small
Small
Medium
Large
X-Large
2X-Large
Have you received your COVID vaccination?
*
Yes
No
Please list the date(s) of your vaccinations. Card will be required for enrollment.
*
Which vaccine did you receive?
*
J&J
Moderna
Pfizer
Signature
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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
CNA-2 Week
Phlebotomy-Hybrid 6 Week
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Total
$
0.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
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