Bethel House Training Institute
2120 N Woodlawn, Ste 350, Wichita, KS 67208 Ph: 316-771-7316 Fax: 316-364-3775
Enrollment Application
PERSONAL INFORMATION
Name
First Name
M.I
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Social Security Number
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Have you ever been a CNA Before?
Yes
No
COURSE INFORMATION
Desired Course:
Certified Nurse Aide
Certified Medication Aide
Home Health Aide (HHA)
CNA Update
CMA Update
CNA State Test
Operator
Phlebotomy
Preferred Schedule:
Morning
Evening
Hybrid
CRIMINAL BACKGROUND
Have you ever been convicted of a felony?
Yes
No
IF YES, PLEASE EXPLAIN
EDUCATION
High School Diploma or GED:
Yes
No
High School Attended
College Attended
Back
Next
EMERGENCY CONTACT INFORMATION
Emergency Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship
PAYMENT OPTIONS
Payment Option
Pay in Full
Financial Aide (SRS or Workforce)
Payment Arrangement
CERTIFICATION
I certify that the answers given in this application are true and complete to the best of my knowledge. I understand that false or misleading information in this application may result in my release from the course.
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did you hear about Bethel House Training Institute? (Optional)
Billboard
LED Sign
Yard Sign
Newspaper
TV
Radio
Flier
Internet
Personal Reference
Name on the back of Flier
Name of the website you found BHTI on
Name of Personal Reference
Preview PDF
Submit
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