Sother Home Health Aide School – Enrollment Application

Enrollment Application
Date of Birth

MonthDayYear
Date
Gender

MaleFemaleOther
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a High School Diploma or GED?

YesNo
Highest Level of Education Completed
Are you at least 18 years old?

YesNo
Do you have any prior healthcare experience?

YesNo
Consent & Agreement

✅ I certify that the information provided is true and correct to the best of my knowledge.
✅ I understand that submitting this application does not guarantee admission.
✅ I agree to comply with the policies and procedures of Sother Home Health Aide School.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Enrollment Application