CCHT Program Registration Form

Name*

First NameLast NameSuffix

DOB*

Date

Email*

Confirmation Emailexample@example.com

I understand that when I am scheduled for the in-person enrollment appointment, in addition to other legal documents, I must bring a copy of my SSN card. (ONLY APPLIES TO MEDICATION AIDE, PHARMACY TECH, CNA, MEDICAL ASSISTANT AND PHLEBOTOMY PROGRAMS.*

Check here to indicate understanding

If you are registering for the Medication Aide Program, do acknowledge that before you complete this online registration, make sure you currently work in (employed at) either a nursing home (long-term care) facility or an assisted living facility or a licensed group home (caring for IDDS patients), or the jail.· If you do not work in any of the above facilities, you are not eligible to register for the Medication Aide program. · If you do work in either of the above facilities, you are eligible and can proceed with registration. Begin by reading the information below in its entirety.*

Check here if you ARE registering for the Medication Aide program and you acknowledge understanding of the employment requirements for eligibility of enrollment in the Medication Aide ProgramCheck here if you are NOT registering for the Medication Aide Program

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Course of Interest?*

Enter course session start date you are interested in *

How did you hear about CHOEZEN CAREERS AND HEALTHCARE TRAINING?*

If you have chosen Medication Aide, CNA, Pharmacy Tech, Medical Assistant, Phlebotomy or BLS Instructor training, Why are you interested in becoming a Medication Aide, CNA, Pharmacy Tech, Medical Assistant, Phlebotomist or BLS Instructor? (Enter "Not applicable" if you've chosen a different course)*

if "Other Referral" Please enter referral name*

I own or have access to a smart phone and/or computer/laptop with internet access?*

Did you graduate from High School or have a GED*

High School Diploma or GED is required for Medication Aide, Medical Assistant, Pharmacy Tech, and Phlebotomy Programs

$100.00 Application Fee (Non-refundable)*

CCHT Application Fee

Application/Registration fee is non-refundable but does apply towards your total tuition / course cost if accepted into your program of choice.

$100.00

Total

$0.00

Credit Card

I certify that the information and my answers on this document are true and complete to the best of my knowledge. I understand that my application does not confirm my admission or enrollment into any of the CCHT programs or courses. If I am accepted into any of the CCHT programs, I understand that any false or misleading information contained in my application or interview, regardless of the time of discovery, may result in my dismissal from the program. I understand that all information on this application is subject to verification and I consent to and understand the following may occur:

Criminal history background check
Reference check (s) of former/current employers and/or educational institutions.

Signature*

CCHT Training Registration Form

Credit Card