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
Format: (000) 000-0000.
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 (Now Enrolling, Call for Schedule)Hybrid Certified EKG Technician 4 weeks (Begins Jan. 2026)Hybrid National Phlebotomy Technician Training 20 days (Begins December 1, 2025)National Phlebotomy Training 12 days EveningsHybrid Patient Care Technician (Begins July 31, 2025)Certified Medical Assistant In- Person/Hybrid Tues and Thurs Evenings ( Begins January 2026) NOW ENROLLINGIV Certification (8 Hours) for LPN, RN and EMT (Call for schedule)Refresher Phlebotomy Course (8 hours) for LPN, RN, EMT and MAs new graduates, and students only (CALL FOR SCHEDULE)
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 8+ )

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, CALL 501. 240.6684 FOR INVOICE)
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 ). Must answer.

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

YesNo
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