Healthcare Skills Scholarship Interest Form

Healthcare Skills Scholarship Interest Form

This form collects basic information from individuals interested in nursing skilled trades to help connect them with relevant opportunities and resources.
Student Name*

First NameLast Name
Student Email*
example@example.com
Did you recently graduate from high school or a GED program in 2023, 2024, or 2025?*

Yes (you may be eligible for Michigan Achievement Skills Scholarship)No (You are not eligible for Michigan Achievement Skills Scholarship)
Do You Receive Snap Benefits AND live OUTSIDE of Detroit? (You may be eligible for funding through Skilled U.S.)*

Yes, I receive Snap Benefits and I do NOT live in Detroit.No, I do not receive Snap Benefits.
What city do you live in? (Determines what funding you may be eligible for)*
Student DOB*
Student Phone Number*
Please enter a valid phone number.
Student Age*
Do You have A Copy Of Your High School Diploma or GED Certification?*

YesNo
Do you live in Wayne County?*
Will you use your 2025/2026 Michigan Achievement Scholarship for college?

NoYes
Have you ever been convicted of a felony?

NoYes
Name of High School or GED Training Center
High School or GED Graduation Date*
Do you have a valid government-issued ID? *
Upload Valid ID

Cancelof
Copy of Your High School Diploma or GED

Cancelof
Which Program Are You Interested In? (Select all that apply)*

CNA (3 Week Classes/ Evening Classes are Hybrid Only (3pm-9pm)Phlebotomy (4-Week Classes/ Hybrid Evenings Only (4pm- 9pm)EKG (2- Week Classes/ Hybrid;
Which CNA class are you interested in?*

Sept 15- Oct 1, 2025Oct 13- Oct 29, 2025Nov 3- Nov 19, 2025Jan 5- Jan 21, 2026Feb 2- Feb 18, 2026Mar 2- Mar 18, 2026Mar 30- April 15, 2026April 27-May 13, 2026June 1-June 17, 2026June 22-July 8, 2026July 13- July 29, 2026
Select a Class Time:*

Day (0800-2:30)Evening (3pm-9pm)
Select a Class Type:*

In-PersonHybrid (combo of online & in-person)
Parent's Phone Number (For student's under 18)
example@example.com
Parent’s Email Address (for students under 18)
example@example.com
Who referred you? *
Refer a friend and Earn Free Money! Earn $100 for every friend that successfully completes the program through the Michigan Achievement Skills Scholarship.
Additional information:
Please add any additional information that may help us ensure that we understand your needs.
Should be Empty: