CCHT Program Registration Form

CCHT Training Registration Form

OCTOBER 8th MEDICATION AIDE CLASS CLOSED FOR REGISTRATION
Name*

First NameLast NameSuffix
DOB*

MonthDayYear
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 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 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.
Signature*

Clear
Should be Empty:

CCHT Training Registration Form

Credit Card