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

Do you have a high school diploma or GED?*

YesNo

Are you at least 18 years old?*

YesNo

Please select the class you would like to attend:*

*Registration will close 1 week prior to class start date.

What time are you available to attend required student orientation? *

Orientation is required.

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

By signing below I authorize permission of Essential Healthcare Academy to run a criminal background report. 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*

Registration Fee is required to reserve your seat and is non-refundable. The remaining balance must be paid in full prior to class end date and attending clinical/externship. Failure to do so, will result in a delay in receiving certificate of completion and taking state or national exam.

My Products

CNA Registration Fee4% online processing fee will be applied

$225.00

QMA Registration Fee4% online processing fee will be applied

$225.00

Phlebotomy4% online processing fee will be applied

$100.00

Medical Assistant4% online processing fee will be applied

$100.00

Insulin Registration4% online processing fee will be applied

$225.00

State Exam Review4% online processing fee will be applied

$100.00

Enter coupon

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Student Enrollment Form