PHCT SCHOOL
Certified to Operate by SCHEV
General Information Form
Student Name
*
First Name
Middle Name
Last Name
D.O.B
*
-
Month
-
Day
Year
Date of Birth
Age
*
Gender
*
Please Select
Male
Female
N/A
Ethnicity
*
Please Select
Asian
Black / African American
Arab / Middle Eastern
Caucasian / European American
Caribbean / Pacific Islander
North / Native American
Spanish / Latin American
Others
Legal Status
*
Please Select
US Citizen
US Permanent Resident (LFP)
Legal US Resident
Current US Visa Status
Other
Provide a Copy of US Legal Status
SSN
Social Security Number
Education Background
Highest Level of Education
*
Please Select
High School
Vocational School
Community College
College / Institute
University
Other
Number of Years Attended
*
Please Select
0-1
1
2
3
4
5
6
Name of Resent School Attended
High School/College/University
Graduation Year
*
Please Select
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
Certificate Earned
*
Please Select
General Educational Development (GED)
High School Certificate
Diploma
College Degree
University Degree
Masters Degree
PhD (Doctor of Philosophy)
No Degree
Other
Provide a Copy of School Certificate
Certificate Issue Date
-
Month
-
Day
Year
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Contact Information
Phone Number
*
Home Number
Work Number
Email
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Emergency Contact Information
Contact Person
*
First Name
Middle Name
Last Name
Phone Number
*
Home Number
Email
Relationship
*
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Course Information
Course/Program
*
Please Select
Phlebotomy Technician (CPT)
Medical Assistant (CCMA)
EKG Technician(CET)
Nurse Aide (NA)
Medication Management
Personal Care Aide (PCA)
Medication Aide
Academic Year
*
Please Select
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
Admission Date
*
-
Month
-
Day
Year
Month Enrolled
*
Please Select
January
February
March
April
May
June
July
August
September
October
November
December
Start Date
*
-
Month
-
Day
Year
Projected End Date
*
-
Month
-
Day
Year
Tuition Cost ($)
*
Down payment ($)
*
1st Payment Date
*
-
Month
-
Day
Year
Payment Method
*
Please Select
Debit / Credit Card
PayPal
Zelle
Cash
Check
Money Order
Student Documents
*
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Upload File (Please attach a copy of your ID & High School Certificate or GED)
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Date Signed
*
-
Month
-
Day
Year
Student Signature
*
School Administration Dept.
For official use only
Application Status
Please Select
Registered
Enrolled
Signed Application Form
Application On Hold
Cancelled Course
Other
Student Code
Please Select
24-001
24-002
24-003
24-004
24-005
24-006
24-007
24-008
24-009
24-010
24-011
24-012
24-013
24-014
24-015
24-016
24-017
24-018
24-019
24-020
24-021
24-022
24-023
24-024
24-025
24-026
24-027
24-028
24-029
24-030
24-031
24-032
24-033
24-034
24-035
24-036
24-037
24-038
24-039
24-040
Course Status
Please Select
Current Student
Next Start Date
Completed Course
Graduated
Class on Hold
Changed Course
Dropped Course
Other
Completion Date
-
Month
-
Day
Year
Certificate Earned
Please Select
YES
NO
OTHERS
Certificate Issue Date
-
Month
-
Day
Year
License Earned
Please Select
NHA - Certified Clinical Medical Assistant (CCMA)
NHA - Certified Phlebotomy Technician (CPT)
NHA - Certified EKG Technician(CET)
FirstAid / CPR
N/A
License Issue Date
-
Month
-
Day
Year
Employment Status Year 1
Please Select
Employed
Unemployed
Unknown
Other
Employment Status Year 2
Please Select
Employed
Unemployed
Unknown
Other
Employment Status Year 3
Please Select
Employed
Unemployed
Unknown
Other
School Adminstrator
Please Select
Ms. Sharon
Mrs. Korkor .E.
G-Note
Student tasks & Notes:
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Tuition Payment Report
For official use only
Reason for Tuition discount:
Please Select
Paid in Full
WIOA Student
VIEW Student
GI Bill Student
VRRAP Student
MyCAA Student
Absolute Home Care Services
Referral Discount
PHCT Promotions Discount
PHCT Scholarship Offer
N/A
Others
Next Payment Date:
-
Month
-
Day
Year
Payment 1 ($)
Payment 2 ($)
Payment 3 ($)
Payment 4 ($)
Payment 5 ($)
Payment 6 ($)
Payment Status:
Please Select
Paid in Full
Current Payment Plan
Refund Issued
On Hold
Past Due Date
Sent to Collections (b/f)
Others
Total Amount Paid
Total Balance
Upload Payment Receipts:
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Choose a file
Upload Receipt Copies for: (Debit/Credit Card Payments, Checks, Money Orders & Cash Payments, etc.)
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Administrators Name:
Please Select
Ms. Sharon
Mrs. Korkor .E.
Ms. Darelle K.
1549 Old Bridge Rd. # 208, Woodbridge VA, 22192. Tel: 571-494-0032.
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