Student Full Name
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First Name
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Student Enrollment Form
Fill out the form carefully for registration
Birth Date
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Gender
*
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Address
*
Street Address
Street Address Line 2
City
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Student E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Work Number
-
Area Code
Phone Number
Student Job Occupation
*
Emergency Contact Information
*
Emergency Contact Number
*
-
Area Code
Phone Number
Courses
*
AHE Program
Medical Assistant
Medical Assistant Combo
Phlebotomist Technician
CPT Workshop (JAX Florida)
How Many Years Of Healthcare Experience?
*
0
1
2
3
4
5
6
7
8
9
10+
Reference
Desired Course Schedule.
*
Weekday Night Class
Weekend Day Class
Online With (On-site Clinicals)
Please Indicate The Course Month Below.
Please Place Your Course Date Below.
*
List Previous Healthcare Skills
Please Take A Copy Of Student Identification
Browse Files
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Please Take A Copy Of Your GED Or High School Diploma
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New Student Deposit Instructions:
If you have already made the payment for your deposit there is no need to fill out that section again. Instead, proceed to complete the new student registration form. Once you have finished the registration process, you will receive an email welcoming you as a new student. To ensure a hassle-free enrollment, it is essential to have a card on file. This can be done by filling out a bank draft authorization form. The payment options for your course tuition must be settled before the start of classes to ensure that you are fully enrolled. We understand that the enrollment process can be overwhelming, but we are here to help you every step of the way. If you have any questions or concerns, please do not hesitate to contact us. Our team is dedicated to providing you with the support you need to succeed in your academic journey. We look forward to welcoming you as a new student and helping you achieve your goals.
Payment Schedule
*
Weekly
Biweekly
Pay In Full
Half
Credit Card Authorization Form (Please Print Out)
New Student Deposit & Payment Options
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Name: A to Z
Name: Z to A
Price: Low to High
Price: High to Low
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( X )
Medical Assistant Deposit
$
50.00
(This is a nonrefundable deposit of $50.00. The deposit will go towards your tuition and hold your spot.)
Medical Assistant Combo Deposit
$
50.00
(This is a nonrefundable deposit of $50.00. The deposit will go towards your tuition and hold your spot.)
Phlebotomy Technician Deposit
$
50.00
(This is a nonrefundable deposit of $50.00. The deposit will go towards your tuition and hold your spot.)
Phlebotomy Technician Workshop Deposit
$
50.00
(This is a nonrefundable deposit of $50.00. The deposit will go towards your tuition and hold your spot.)
Phlebotomy Technician Workshop (Full Amount)
$
555.00
Phlebotomy Technician (Full Amount) Summer Deal
$
555.00
Student Paid In FULL AMOUNT Phlebotomy Technician
$
1,550.00
(This includes a $150 deposit & $1400 Phlebotomy Technician Course Tuition.)
Student Paid In FULL AMOUNT Medical Assistant
$
2,400.00
(This includes a $200 deposit & $2200 Medical Assistant Course Tuition.)
Certification Exam Fee
$
215.00
Certification Exam Fee 2
$
215.00
Enter coupon
Apply
Total
$
0.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
I verify the accuracy of all my provided information and confirm that it is not false. As a student, I consent to either placing a card on file or making full payment. I acknowledge that a late payment will incur a $25.00 late fee. I confirm my understanding that the deposit is nonrefundable and cannot be returned.
*
Thank You For Accepting Us !
Greetings! We are delighted to inform you that you will soon be receiving a welcome email for new students. This email will contain comprehensive information about your courses, including details about the curriculum, study materials, and our school's policies and standards. Additionally, you will find an invoice arrangement for your convenience, allowing you to make weekly or biweekly payments. Furthermore, we kindly request that all students carefully review and adhere to our school contract to ensure a smooth and successful academic journey, while also avoiding any potential consequences. We look forward to welcoming you to our institution and supporting you throughout your educational experience.
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