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?
*
CNA
Phlebotomy
EKG
What are your goals after completing the program?
Please upload your recent photo ID
*
Browse Files
Drag and drop files here
Choose a file
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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 $50 nonrefundable deposit. This is returned in the form of a CPR/BLS certificate. Can you pay this?
*
Yes
No
Do you want free money? Refer anyone to our program and get $50 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
Print Form
Submit
Submit
How did you learn about this virtual course?
Facebook
Twitter
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YouTube
Search Engine
Online Ads
Referral
Other
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