Student Registration Form

UNITY HEALTHCARE TRAINING ACADEMY LLC

3201 South Medford Dr. Ste. 7

Lufkin, Tx. 75901

(936) 632-1861
Student Registration Form

Students Full Name

First NameMiddle NameLast Name
Gender
Student Age
Present Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email
Students Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please List Allergies
Have you ever been convicted of a crime? If yes please describe in the next question.
Please list any crimes you were convicted of along with the dates below.
First Name Last Name understand Unity Healthcare Training Academy LLC is required to obtain a criminal background check for all applicants I also understand a successful background check is not a guarantee for approval into a program. A background check containing felonies however will be reviewed but also may prevent a student from being able to enroll into a program. Signature
Which program are you enrolling into?*
Upload a clear copy of your ID/ DL ( Can not be Expired)*

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Upload a clear copy of your Social Security Card *

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Upload a clear copy of your high school diploma or college transcript *

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My Products

UHTA Down-payment

To enroll in any program except Medical Assistant a candidate must pay this minimum fee, and make arrangements to pay the rest of the tuition with the program director. If you would like to pay in full please call 936-632-1861 for an invoice link.

$300.00 Quantity
Item subtotal:$0.00

Medical Assistant Course Down-payment

This payment link is only for Medical Assistant Students. If you would like to pay in full please call 936-632-1861 for an invoice link.

$400.00 Quantity

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

Afterpay

Date

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Date
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