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

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Please enter a valid phone number.

Course of Interest?*

Enter course session start date you are interested in*

How did you hear about CCHT / Pumping Heart CPR?*

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*

$100.00 Application Fee (Non-refundable)*

CCHT Application FeeApplication/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 listed

Signature*

Training Registration Form

Credit Card