ZATC, LLC Application

Zayleigh Alexander Training Center (ZATC), LLC - Online Application
Full Name*

First NameMiddle NameLast NameSuffix
Maiden Name or Previously Used Name(s)*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Emergency Contact*

First NameLast Name
Relationship of Emergency Contact*
Emergency Contact Phone Number*
Please enter a valid phone number.
Are you able to lift a minimum of fifty (50) pounds?*
Do you have any medical restrictions or medical conditions?*
Please list medical conditions or medical restrictions
Have you ever been convicted of a felony or misdemeanor?*
Please list conviction(s) with date
Consent to Background Check
By signing below, I consent to have a background check completed by Zayleigh Alexander Training Center (ZATC), LLC. I acknowledge that documentation of a successful background check must be received prior to the start of the selected program/certification. I authorize Zayleigh Alexander Training Center, LLC and its employees to provide a copy of my background check, and agree to release any other required information, to the clinical site for purposes of training.
Signature*

Clear
Today's Date*

MonthDayYear
Date
A deposit of $200.00 must be paid at time of application submission to reserve a seat in the program. The balance is due prior to the last day of the course. To receive the certificate of completion, all fees must be paid and all equipment on loan from the school must be returned in satisfactory condition.

Tuition payments may be refunded only if requested in writing no more than three (3) days from the date of application. Refunds will be issued within 30 business days. A $50 non-refundable fee will be deducted from the balance. If a student withdraws from the course, no refund shall be issued regardless of time passed. If the student does not pass the background check, student will receive a full refund less the background check fee.
By signing below, I signify that:
- I have read this application in its entirety.
- I certify that all information provided regarding my academic history, work experience, and personal details must be accurate and completely honest.
- I agree to the policies and procedures listed in the handbook and syllabus.
- I understand that clinical dates and times are subject to the discretion of the clinical director and the facility at which clinicals will take place.
- I consent to release information to the clinical facility for clearance as required for the purposes of completing clinicals.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Enrollment Deposit
Thank you for submitting an application to Zayleigh Alexander Training Center, LLC!

You will be notified via email once your application has been reviewed.
Clicking submit will take you to the payment form. As a reminder, the application is not complete until the payment is submitted and the transaction is completed.
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Zayleigh Alexander Training Center (ZATC), LLC - Online Application

Consent to Background Check

Enrollment Deposit