A-List Healthcare Training Academy CNA Program Pre-Enrollment Form
Application is approved based on criminal background results. Once the results are ready, someone from administration will contact you and review the next enrollment steps and collect the required deposit.
Name
*
First Name
Middle Name
Last Name
Suffix
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Social Security Number
*
Driver License Number
*
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Do you hold a High School Diploma or GED?
*
Please Select
Yes
No
Do you hold any Associate's or Bachelor's Degrees?
*
Please Select
Yes
No
Last School Attended
*
Graduation Date
-
Month
-
Day
Year
Date
Which class are you interested in joining
*
Please Select
In person Evening
Hybrid Online
What cohort are you interested in?
*
Please Select
December 17 2024
January 13 2025
February 10 2025
March 10 2025
Do you have access to Technology?
*
Smartphone
Computer
Tablet
None
Please tell us why you are interested in this program
*
Please upload a copy of Driver's License or State ID
*
Browse Files
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Choose a file
I attest that all information disclosed is correct. I authorize A-List Healthcare Training Academy to use pertinent information provided on this form to determine eligibility for enrollment and I acknowledge the required application fee is non- refundable.
Cancel
of
Signature
*
Additional Documents
Browse Files
Drag and drop files here
Choose a file
Upload a copy of CPR certification if available and TB skin test results.
Cancel
of
How did you hear about our program?
*
Friend/Family
Social Media
Searching the Web
Flyer/business card
Other
Name of Referring Person
First Name
Last Name
Application Fee
*
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Application Fee
This is a Non-refundable fee. Applications will not be processed until application fee is made. This fee is separate from the overall tuition payment.
$
85.00
Quantity
1
2
3
4
5
6
7
8
9
10
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.
ACH Bank Transfer
Afterpay
After submitting the form, you will be redirected to Afterpay to complete the payment.
Submit
Submit
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