CERTIFIED MEDICAL ASSISTANT STUDENT APPLICATION
Visionary Health Career Training Institute LLC
Please fill out the entire form below.
Medical Assistant Student Application form
Program Applying For
Please Select
Certified Medical Assistant Training (In-Person)
Preferred Start Date
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Month
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Day
Year
Next available class offering (listed on website)
Name
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First Name
Middle Name (if applicable)
Last Name
Email address
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example@example.com
Cell Phone Number
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Please enter a valid phone number.
Social Security Number
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Social Security Card
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Upload a copy of your government issued photo ID. (passport, visa, state ID, state driver's license)
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Government Issued Photo
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Home Address
Street Address
Street Address Line 2
City
State
Zip Code
Have you previously applied to Visionary Health Career Training Institute?
Yes
No
Have you ever been a Medical Assistant?
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
Are you 18 years of age or older?
*
Yes
No
Have you ever been convicted of a felony?
Yes
No
If convicted, please explain
Education
High School Attended
High School Address
City, State
High School Start Date
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Month
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Day
Year
Date
High School End Date
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Day
Year
Date
Did you graduate high school?
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Do you have a high school diploma or GED?
Diploma
GED
College
College Attended
College Address
College Start Date
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Month
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Day
Year
Date
College End Date
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Month
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Day
Year
Date
Degree type
Associate
Bachelors
Other
Did you graduate college?
Yes
No
Other Education
Other Education Program
Other Education Address
Other Education Start Date
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Month
-
Day
Year
Date
Other Education End Date
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Month
-
Day
Year
Date
Did you graduate from Other Education?
Yes
No
Degree/Certificate of Completion Earned
Yes
No
References
Someone who can speak about your personal or professional history
Reference #1
First Name
Last Name
Relationship
Company
Phone Number
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Address
Street Address
Street Address Line 2
City
State
Zip Code
Reference #2
Reference #2
First Name
Last Name
Relationship
Company
Phone Number
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference #3
Reference #3
First Name
Last Name
Relationship
Company
Phone Number
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Address
Street Address
Street Address Line 2
City
State
Zip Code
Employment History
List your jobs (up to 3 most recent)
Employer #1
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor
Name
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 #2
Name
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
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State / Province
Postal / Zip Code
Supervisor
Name
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 #3
Name
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor
Name
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
Are you a U.S. military veteran?
Yes
No
Branch of Armed Forces
Rank At Discharge
Dates Served
-
Month
-
Day
Year
Start date
Type Of Discharge
Dates Served
-
Month
-
Day
Year
Discharge date
If Other Than Honorable, Explain
Payment Options & Authorization
Choose your payment option below:
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CERTIFIED MEDICAL ASSISTANT TRAINING IN-PERSON CLASS
12-week class at Main Campus - Medical Assistant classes consist of IN-PERSON classroom, lab skills, and 40 hours internship. Non-refundable after 72 hours from application submission.
$
2,000.00
Payment Options
Pay in full (application fee $150 & tuition $1,850)
Pay partial (application fee $150 & tuition deposit $850)
Pay remaining tuition balance ($1,000)
Pay via Denefits Financing
If Paying Via Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
If Paying Via Denefits Financing
Approval code
Check the box to acknowledge:
*
Payment will be processed immediately based on your chosen payment option above. ANY REMAINING BALANCE MUST BE PAID TWO WEEKS BEFORE YOUR FINAL EXAM.
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
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Date
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