McKallen Medical Training
Home Health Aide Class Registration Form
Your Name:
*
First Name
Last Name
Email Address: (Gmail preferred)
*
Email
SSN:
*
example: 123-25-9870
Date of Birth
*
-
Month
-
Day
Year
MM-DD-YYYY
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
-
Area Code
Phone Number
CNA license Number
CNA license Expiration Date
High School:
*
Name of School
GED/Dipolma
*
Yes
No
still enrolled in High School
Year of GED/Diploma completion
*
Year
Emergency Contact
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Uniform Top
X-Small
Small
Medium
Large
X-Large
XX-Large
Uniform Bottom
X-Small
Small
Medium
Large
X-Large
XX-Large
Do you have access to a computer, laptop, or Mobile phone to receive and complete assigned coursework?
*
Yes
No
You may be eligible for financial aid if you are between 16-24 years old and are experiencing one or more of the following:
*
You qualify as low income
You're receiving disability financial assistance
You are currently homeless
You did not complete high school
You are currently in foster care
You recently aged out of foster care
None of the above apply to me
How did you hear about McKallen Medical Training?
Facebook
Instagram
Indeed
Google
Referral
My Products
prev
next
( X )
Course Deposit
$
20.00
Three-Day Cancellation: An applicant who provides written notice of cancellation within three (3) business days, excluding weekends and holidays, of executing the enrollment agreement is entitled to a refund of all monies paid, excluding the $150 non-refundable registration fee.
Tuition Finacing via Paypal
$
1,200.00
Total
$
0.00
Credit Card
Submit File(s)
Should be Empty: