Student Application–Align Health Careers Institute, LLC

Student Application
Please select the course you wish to enroll in:*

CPR Instructor Course Fee: $385.00Heart-Saver/First Aid Course Fee: $80.00ACLS Course Fee: $250.00CPR Course Fee: $70.00
Full Name*

First NameMiddle InitialLast Name
Date*

MonthDayYear
Date
Address*

Street Address

Apartment/Unit #

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Age*
Occupation*
Course Applied for*
Please type one of the following in the text box: CPR, ACLS, Heart-Saver/First Aid, and CPR Instructor
Gender*

MaleFemale
How did you learn about this course?*

Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.

If this application leads to enrollment, I understand that false or misleading information in my application or interview may result in my release.
Signature*

Clear
Date*

MonthDayYear
Date
Guardian Signature (If applicable)

Clear
Date (If applicable)

MonthDayYear
Date
Should be Empty:

Student Application