Michigan Achievement Skills Scholarship (MASS)
Free CNA class
Are you a high school graduate of 2023-2025?
Yes
No
Have you used your Michigan Achievement Scholarship already?
Yes
No
Student Information
Student Name
*
First Name
Last Name
Date of Graduation
*
Put N/A if you haven't graduated yet.
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Male
Female
Phone Number
*
Email Address
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which class do you want to attend?
*
September 8(In-Person)
September 8(Hybrid)
September 29 (In-Person)
September 29 (Hybrid)
What are your goals after completing the program?
Please upload your recent photo ID
*
Browse Files
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Does the student have any disabilities, illness, medical conditions, personal problems, etc. that can affect his/her virtual classes/study?
Please choose one
*
I am an adult (18 years above)
I am a minor (17 years below)
Parent/Guardian Details
If under 18
Parent/Guardian Name
First Name
Last Name
Phone Number
Relationship
We require a $100 refundable deposit. This is returned at the end of the program, once successfully completed and pass state exam. Can you pay this?
*
Yes
No
Do you want free money? Refer anyone to our program and get $100 per referral. They must mention your name. Go to our instagram at firststephealthcaretraining to share the Michigan Achievement Skills Scholarship flyer. No limit on referrals!
Yes
No
Others
Student Signature
*
Date
*
-
Month
-
Day
Year
Date
Parent Signature (if under 18)
Date
-
Month
-
Day
Year
Date
Course Deposit
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Deposit
Deposit $100; Transaction fee $6
$
106.00
Quantity
1
2
3
4
5
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10
Pay at school
$
Free
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.
Print Form
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How did you learn about this virtual course?
Facebook
Twitter
Instagram
YouTube
Search Engine
Online Ads
Referral
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