Student Registration Form

Student Registration Form

Provide your details, credentials, and signature to secure your registration for our course offerings.
Student Information
Full Name (as shown on your government ID).*

First NameLast Name
Date of Birth

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Employment Status

EmployedUnemployedStudentEmployer
Please select your course
Please select your course*

Plan A - HCA 75 Hours CoursePlan B - HCA 75 Hours Course Plus CPR/First AidPlan C - HCA 75 Hours Course Plus CPR/First Aid, Nurse Delegation Core & DiabetesPlan D - HCA 75 Hours Course Plus Nurse Delegation Core & Diabetes (No CPR/First Aid)Dementia - Level OneMental Health - Level OneContinuing Education (CEs Annual 12 Hrs)In-Person Skills Lab Course (16 hours) - Two Fridays: 9:00am to 4:00pmNurse Delegation Core (9 hours)Nurse Delegation Diabetes (3 hours)First Aid/CPR/AED Hybrid (Online & In-Person)Traumatic Brain Injury (offered on demand basis)Substance Use Disorder (offered on demand basis)
How did you hear about Sparkle Training Center?*
Today's Date - Must be on the same date you are completing this form!*

MonthDayYear
Date
Should be Empty: