McKallen Medical Training Home Health Aide Registration Form

McKallen Medical Training

Home Health Aide Class Registration Form
Your Name:*

First NameLast Name
Email Address: (Gmail preferred)*
Email
SSN:*
example: 123-25-9870
Date of Birth*

MonthDayYear
MM-DD-YYYY
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*

Area CodePhone Number
CNA license Number
CNA license Expiration Date
High School:*
Name of School
GED/Dipolma*

YesNostill enrolled in High School
Year of GED/Diploma completion*
Year
Emergency Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Start Date*
Uniform Top

X-SmallSmallMediumLargeX-LargeXX-Large
Uniform Bottom

X-SmallSmallMediumLargeX-LargeXX-Large
Do you have access to a computer, laptop, or Mobile phone to receive and complete assigned coursework?*

YesNo
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 incomeYou're receiving disability financial assistanceYou are currently homelessYou did not complete high schoolYou are currently in foster careYou recently aged out of foster careNone 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: