Application & Scholarship Form
The goal of this College is to ensure students complete their coursework in a timely effort, pass all licensure exams and provide a career path that ensures their success in the students' chosen career. The payment of the admission application fee of $50 (non-refundable) must be paid before your application is considered complete and you can register for classes. Please call us at 769-572-7490 or come by the campus to pay your application fee. Thank you again for your patience and your commitment to the College of Health Services and Careers. Marcus A. Chanay, Ph.D., CFRM President
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Female
Male
Perfer not to say
Program(s) of Study intersted in
*
Nursing Assistant
Phlebotomy
EKG
Pharmacy Tech
Medical Billing and Coding
Limited License Radiology
Medical Assistant
Physical Therapy Aid
Which Cohort are you interested in? *4-week classes only: Nursing Assistant, EKG, Phlebotomy*
Cohort 1 (January 5- February 12)
Cohort 2 (February 16- March 13)
Cohort 3 (March 30- April 24)
Cohort 4 (May 11-June 5)
Cohort 5 (June 8- July 10)
Cohort 6 (July 27- August 21)
Cohort 7 (September 8- October 2)
Cohort 8 (October 19- November 13)
Which Cohort are you interested in? *8- week classes only: Pharmacy Tech*
Cohort 2 (February 16- April 24)
Cohort 4 (May 11-August 21)
Cohort 6 (September 8- November 13)
Which Cohort are you interested in? *16-weeks Classes only: Medical Billing & Coding and Limited License Radiology*
Cohort 3 (March 30- July 10)
Cohort 6 (July 27- November 13)
Which Cohort are you interested in? *24- weeks Classes only: Medical Assistant*
Cohort 1 (January 5-June 5)
Cohort 5 (June 8- November 13)
Education
High School
*
High School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Attended From
*
Did you Graduate
*
Yes
No
College
College Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Attended From
Did you Graduate
Yes
No
Degree / Program of Study:
Have you ever been a convicted felony?
*
Yes
No
If yes, please explain :
SCHOLARSHIP APPLICATION
This Scholarship will be awarded to a student pursuing a certificate program from the College of Health Services and Careers and show a need of support. Founders Award Scholarship. An institutional scholarship offered prior to program start to support incoming students who demonstrate commitment to their education and align with the school’s core values. Presidential Scholarship A prestigious institutional scholarship offered prior to program start to recognize incoming students with outstanding academic achievement and leadership potential. For more information on the scholarships please call the school (769)572-7490
Which Scholarship are you applying for ?
Founders Scholarship
Presidential Scholarship
Dean Scholarship
What specialty to you plan to pursue after completion?
*
Whare are your educations & professional goals & objectives?
*
College of Health Services and Careers- Class Registration/ Application Fee
*
prev
next
( X )
Nursing Assistant
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Phlebotomy
$
50.00
EKG
$
50.00
Pharmacy Tech
$
50.00
Medical Billing and Coding
$
50.00
Limited License Radiology
$
50.00
Medical Assistant
$
50.00
Physical Therapy Aid
$
50.00
Credit Card
Signature of Applicant
*
Please verify that you are human
*
Continue
Continue
Should be Empty: