McKallen Medical Training Home Health Aide Registration Form

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
Start Date *
Uniform Top

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Uniform Bottom

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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?

My Products

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

Should be Empty: