Mississippi School of Health Services & Careers Application Form

Full Name*
Application & Scholarship Form
The goal of this College is to ensure students complete their coursework in a timely effort, pass all licensure exams and provide a career path that ensures their success in the students' chosen career.

The payment of the admission application fee of $50 (non-refundable) must be paid before your application is considered complete and you can register for classes.

Please call us at 769-572-7490 or come by the campus to pay your application fee.

Thank you again for your patience and your commitment to the College of Health Services and Careers.

Marcus A. Chanay, Ph.D., CFRM President
Birth Date*
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail*
Gender*

MaleFemalePrefer not to say
Program(s) of Study interested in*

Certified Medical AssistantMedical Billing & CodingNursing AssistantPhlebotomy Tech / PhlebotomistEKG TechnicianPharmacy TechnicianLimited License RadiologistCommunity Health WorkerCOVID-19 Training
EDUCATION
High School*
High School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attended from*
Did you Graduate?*

YesNo
Diploma*
College
College Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attended from
Did you Graduate?

YesNo
Have you ever been convicted of a felony?*

YesNo
If yes, please explain.
Degree / Program of Study
Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attended from
Did you Graduate?

YesNo
Degree / Program of Study
SCHOLARSHIP APPLICATION

This Scholarship will be awarded to a student pursuing a certificate program from the College of Health Services and Careers and show a need of support.
I will be attending the MS School of Health Services and Careers*

Fall SemesterSpring SemesterOther
I will be entering the following program*

Certified Medical AssistantMedical Billing & CodingNursing AssistantPhlebotomy Tech / PhlebotomistEKG TechnicianPharmacy TechnicianLimited License RadiologistCommunity Health WorkerCOVID-19 Training
What specialty to you plan to pursue after completion?*
Whare are your educations & professional goals & objectives?*
Signature of Scholarship Applicant

Clear

Mississippi School for Health Services & Careers - Register for Classes

Certified Medical Assistant - Class Registration$50.00

Class Registration Fee. This fee is non-refundable.

Quantity

Medical Billing & Coding - Class Registration$50.00

Class Registration Fee. This fee is non-refundable.

Quantity

Nursing Assistant - Class Registration$50.00

Class Registration Fee. This fee is non-refundable.

Quantity

Phlebotomy Tech / Phlebotomist - Class Registration$50.00

Class Registration Fee. This fee is non-refundable.

Quantity

EKG Technician - Class Registration$50.00

Class Registration Fee. This fee is non-refundable.

Quantity

Pharmacy Technician - Class Registration$50.00

Class Registration Fee. This fee is non-refundable.

Quantity

Limited License Radiologist - Class Registration$50.00

Class Registration Fee. This fee is non-refundable.

Quantity

Community Health Worker - Class Registration$50.00

Class Registration Fee. This fee is non-refundable.

Quantity

COVID-19 Training - Class Registration$50.00

Class Registration Fee. This fee is non-refundable.

Quantity

Total $0.00

Credit Card

Please verify that you are human*
Should be Empty:

Application & Scholarship Form

EDUCATION

SCHOLARSHIP APPLICATION

Credit Card