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?*

YesNoStill in high school

Are you at least 18 years old?*

YesNo

Are you a veteran?*

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 - Please do not complete this form until you have been approved for funding OR unless you are self pay.*

Registration Fee is non-refundable and non-transferrable.

My Products*

CNA Registration Fee4% online processing fee will be applied

$225.00

QMA Registration Fee4% online processing fee will be applied

$325.00

Phlebotomy4% online processing fee will be applied

$400.00

Medical Assistant4% online processing fee will be applied

$500.00

Insulin Registration4% online processing fee will be applied

$225.00

IV Certification - must be a licensed professional4% online processing fee will be applied

$500.00 Quantity

State Exam Review - returning student contact for discount code.4% online processing fee will be applied

$200.00

Enter coupon

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

Afterpay

Student Enrollment Form

Payment Methods