Course Registration Form

Student Enrollment Form

We ask that you please allow 24-48 hours for your email inquiry to be responded to. Please be aware that we respond to emails in the order in which they are received. Thank you for choosing Aspiring Medical Training Institute. Please answer each question.
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail
example@example.com
Mobile Number
Date

MonthDayYear
Date
Which course are you interested in? Please only choose one class per interest form.

Nursing Assistant 4 weeks + 1 full weekend M-Thurs (Evenings Only)Hybrid Certified Clinical Medical Assistant 22 weeks (Begins July 31, 2025)Online Pharmacy Technician 6 weeks (Begins July 31, 2025)Hybrid Certified EKG Technician 4 weeks (Begins July 31. 2025)Hybrid National Phlebotomy Technician Training 4 weeks (Begins July 31, 2025)National Phlebotomy Training 12 days EveningsHybrid Patient Care Technician (Begins July 31, 2025)Certified Medical Assistant In- Person M-Thurs ( Begins September 1st 2025)IV Certification (8 Hours) for LPN, RN and EMTRefresher Phlebotomy Course (8 hours) for LPN, RN, EMT and MAs new graduates, and students only
CPR training, renewal or new start training dates: Class is 0900-1pm Usually held on 3rd Saturday of the month. (Please call to book a group training for 10+ )

New CPR/BLSRenewal CPR/BLS
Are you a citizen of the United States?
Will you use the self-pay option? (We accept debit, credit, cash, sponsorships and Afterpay)
Have you been identified as having a learning disability? (This will not prevent you from enrolling and being accepted) You must provide proof.

YesNo
Do you have a high school diploma or GED? (Not a requirement but highly recommended as you will have exams). Must answer.

YesNo
Can you speak and read English fluently? (Requirement)

YesNo
This is a fill in the field. Please add appropriate fields and text.
Have you ever been convicted of a misdemeanor, felony or placed on probation in the state of Arkansas, any of the 50 states, or outside of the country? (Failure to disclose this information is an automatic dismissal from the program, specifically Nursing Assistant . Includes (Theft, robbery, murder, forgery, battery, possession of illegal substances, and etc)

YESNO
Should be Empty:

Student Enrollment Form