Essential Healthcare Academy

Student Name*

First NameMiddle NameLast Name

Birth Date*

MonthDayYear

Gender*

Social Security Number*

Required for background check screening

Race*

Required for background check screening

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student E-mail*

example@example.com

Mobile Number*

Education/Enrollment

YesNoStill in high school

YesNo

Please select the class you would like to attend:*

*Registration will close 2 weeks prior to class start date.

Please select required orientation date that corresponds with the class you will be enrolled in.*

Orientation is required.

What size scrubs do you wear? (CNA, Medical Assistant & Phlebotomy only)*

How will you be paying for the cost of the program?*

Please upload a copy of your state issued ID. (Additional documents will be needed prior to start date).**

By signing below I certify that all answers given in this application are accurate to the best of my knowledge. I understand that failure to disclose or falsifying information could result in my dismissal from any course.

Signature

Registration Fee is non-refundable and non-transferrable.

My Products*

CNA Registration Fee