STUDENT APPLICATION
Visionary Health Career Training Institute LLC
Thank you for your expressed interest in Visionary Career Training Institute LLC. Fill out the entire form below.
VHCTI Student Application form
Program Applying For
*
Please Select
CNA Training Program (In-Person)
CNA Training Program (Online hybrid)
Preferred Start Date
-
Month
-
Day
Year
Date
Name
*
First Name
Middle Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Social Security No.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you 18 years of age or older?
*
Yes
No
Are you a citizen of the United States?
*
Yes
No
If no, are you authorized to work in the U.S?
*
Yes
No
Have you ever applied to Visionary Health Career Training Institute?
*
Yes
No
Have you ever been a Certified Nursing Assistant?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
If convicted, please explain
Education
High School
High School Address
High School Start Date
-
Month
-
Day
Year
Date
High School End Date
-
Month
-
Day
Year
Date
Did you graduate high school?
Yes
No
Do you have a high school diploma or GED?
Diploma
GED
College
College
College Address
College Start Date
-
Month
-
Day
Year
Date
College End Date
-
Month
-
Day
Year
Date
Degree type
Associate
Bachelors
N/A
Did you graduate college?
Yes
No
Other
Other Education
Other Education Address
Other Education Start Date
-
Month
-
Day
Year
Date
Other Education End Date
-
Month
-
Day
Year
Date
Did you graduate from Other Education?
Yes
No
Other Education Degree
References
Reference #1
Full Name
First Name
Last Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference #2
Full Name
First Name
Last Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference #3
Full Name
First Name
Last Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employment History
List your jobs (Up to the last 3)
Employer Name
Phone Number
Please enter a valid phone number.
Supervisor
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Responsibilities
Starting Salary
Ending Salary
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Reason for Leaving
May We Contact Supervisor?
Yes
No
Employer #2
Employer Name
Phone Number
Please enter a valid phone number.
Supervisor
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Responsibilities
Starting Salary
Ending Salary
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Reason for Leaving
May We Contact Supervisor?
Yes
No
Employer #3
Employer Name
Phone Number
Please enter a valid phone number.
Supervisor
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Responsibilities
Starting Salary
Ending Salary
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Reason for Leaving
May We Contact Supervisor?
Yes
No
Military Service
Branch
Rank At Discharge
To
-
Month
-
Day
Year
Date
From
-
Month
-
Day
Year
Date
Type Of Discharge
If Other Than Honorable, Explain
Select Your Program
The V Offers:
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(REQUIRED) APPLICATION FEE
Non-refundable after 72 hours from application submission
$
150.00
Quantity
1
2
3
4
5
6
7
8
9
10
CNA ONLINE (HYBRID) CLASS FEE
6-week class online - CNA classes consist of ONLINE classroom, and in-person lab skills, and clinical training in a skilled nursing facility.
$
800.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Options
Pay in full
Pay in weekly installments
CNA TRAINING IN-PERSON CLASS FEE
6-week class at Main Campus - CNA classes consist of IN-PERSON classroom, lab skills, and clinical in a skilled nursing facility.
$
600.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Options
Pay in full
Pay in weekly installments
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Payment Options & Authorization
Check the box to acknowledge:
*
Payment will be processed based on your chosen payment option above. You will be responsible for the immediate payment of the total amount, including the application fee. For the remaining balance, you will receive weekly invoices via email. The full remaining balance must be paid by Monday of the fifth week of class.
Disclaimer and Signature
If this application leads to acceptance to Visionary Health Career Training Institute, LLC, I understand that false or misleading information in my application may result in dismissal from the program.
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE, CORRECT AND COMPLETE.
Signature
*
Date
*
-
Month
-
Day
Year
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