Student Enrollment Application
Please complete all required fields and upload requested documents.
Payment Options
Financing
Pay in Full ($1100)
Student Information
Student Name
*
First Name
Middle Name
Last Name
Mobile Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Permanent Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you at least 18 years of age?
*
Yes
No
Student Date of Birth
*
/
Month
/
Day
Year
Date
Are you a citizen of the United States?
*
Yes
No
Social Security Number
*
State ID or Driver's License Number
*
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Please Upload Social Security Card
*
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Please upload Drivers License or Government Issued ID
*
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Gender
*
Male
Female
Non Binary
Prefer Not to Say
Emergency Contact Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
*
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Additional Student Information
Which best describes your ethnicity:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Do you have any physical conditions that would would limit your ability to perform?
Yes
No
If yes, please specify restrictions and required accommodations.
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Educational Background
Did you graduate from High School?
*
Yes
No
Did you obtain a GED or equivalent education?
*
Yes
No
Name of High School
*
Location of High School (City, State)
*
Graduation/Completion Date
*
-
Month
-
Day
Year
Date
Did you attend college?
*
Yes
No
Did you graduate from college/university?
*
Yes
No
Name of College/University?
*
Location of College/University?
*
Graduation/Completion Date
*
-
Month
-
Day
Year
Date
Please upload a copy of your High School Diploma or GED Certificate.
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Personal Background
Have you ever been convicted of a felony?
*
Yes
No
If yes, please upload documentation to include: Date of Felony Charge, Nature of Felony, Which Court, and Final Outcome. Also upload copies of the court records.
*
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Limit: 4 Files
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Program Enrollment
TruCare Medical Training offers multiple programs. Please select the program you are applying.
Which program are you applying for?
*
Please Select
Certified Nursing Assistant - Day Program
Certified Nursing Assistant- Evening Program
CPR Training
BLS Training
First Aid Training
Do you have any experience in the healthcare field?
*
Yes
No
Why are you pursuing a career in healthcare?
*
Do you plan to pursue additional education or training after obtaining the certification you are applying for?
Yes
No
How did you hear about TruCare Medical Training Center?
Peer Referral
Instagram
Facebook
Web Search (Google, Yahoo, other)
Other
Please provide any additional information we may need to know when reviewing your application.
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References
Please provide a minimum of 1 reference.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
*
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
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Application Fee
Application fee is non-refundable and non-transferrable.
$
50.00
Credit Card
Student Acknowledgement
By my signature below, I certify the information I provided within this form is true and correct to the best of my knowledge. I also understand that any false statements or deliberate omissions on this form affect the outcome of my enrollment status.
Signature
*
Date
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Month
-
Day
Year
Date
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