BMG Vocational Academy – Student Enrollment Application
Professional mobile-friendly enrollment application. After submission, send a confirmation email to the applicant and generate a PDF copy of the completed application.
Student Information
Legal First Name
*
Middle Name
Legal Last Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Street Address
*
City
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Other
ZIP Code
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Mail
Other
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Program Selection
Program Selection
*
Medical Billing Certification
Project Management Certification
Administrative & Office Worker Certification
Preferred Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Training Format
*
In-Person
Virtual
Hybrid
Preferred Schedule
*
Morning
Afternoon
Evening
Weekend
How did you hear about BMG Vocational Academy?
Education
Highest education level
*
Please Select
Less than high school
High school diploma or GED
Some college
Associate degree
Bachelor’s degree
Graduate degree
Vocational/technical training
Other
Do you have a high school diploma or GED?
*
Yes
No
High school name
Graduation year
College or vocational training details
Degrees or certificates earned
Upload education documents
Upload a File
Cancel
of
Employment/Career
Currently Employed?
*
Yes
No
Employer
Job Title
Seeking Employment?
*
Yes
No
Career Goals
Reason for Enrolling
*
Interested in Job-Placement Assistance?
*
Yes
No
Resume
Upload a File
Cancel
of
Training Readiness
Do you have access to a computer or laptop for training?
*
Yes
No
Do you have reliable internet access?
*
Yes
No
What is your level of basic computer skills?
*
Please Select
Beginner
Intermediate
Advanced
What is your experience with Microsoft Office?
*
Please Select
None
Basic
Intermediate
Advanced
Please describe any barriers that may affect your ability to complete training.
Support Services
Assistance is subject to availability and not guaranteed.
Which support services would you like to request?
*
Transportation
Childcare Resources
Technology
Internet
Resume Assistance
Interview Preparation
Employment Assistance
Career Coaching
None
Other
If you selected Other, please specify
Program Questions
Selected Program
*
Medical Billing Certification
Project Management Certification
Administrative & Office Worker Certification
Medical Billing: Experience with medical billing
1
2
3
4
5
No experience
Extensive experience
1 is No experience, 5 is Extensive experience
Medical Billing: Comfort with medical terminology
1
2
3
4
5
Not comfortable
Very comfortable
1 is Not comfortable, 5 is Very comfortable
Medical Billing: Comfort with insurance processes
1
2
3
4
5
Not comfortable
Very comfortable
1 is Not comfortable, 5 is Very comfortable
Medical Billing: Comfort with coding
1
2
3
4
5
Not comfortable
Very comfortable
1 is Not comfortable, 5 is Very comfortable
Medical Billing: Comfort with claims processing
1
2
3
4
5
Not comfortable
Very comfortable
1 is Not comfortable, 5 is Very comfortable
Medical Billing: Comfort with healthcare administration
1
2
3
4
5
Not comfortable
Very comfortable
1 is Not comfortable, 5 is Very comfortable
Project Management: Experience with planning
1
2
3
4
5
No experience
Extensive experience
1 is No experience, 5 is Extensive experience
Project Management: Comfort working with teams
1
2
3
4
5
Not comfortable
Very comfortable
1 is Not comfortable, 5 is Very comfortable
Project Management: Comfort managing budgets
1
2
3
4
5
Not comfortable
Very comfortable
1 is Not comfortable, 5 is Very comfortable
Project Management: Comfort scheduling tasks and milestones
1
2
3
4
5
Not comfortable
Very comfortable
1 is Not comfortable, 5 is Very comfortable
Project Management: Comfort meeting deadlines
1
2
3
4
5
Not comfortable
Very comfortable
1 is Not comfortable, 5 is Very comfortable
Project Management: Experience with project management software
1
2
3
4
5
No experience
Extensive experience
1 is No experience, 5 is Extensive experience
Administrative & Office Worker: Experience with Microsoft Word
1
2
3
4
5
No experience
Extensive experience
1 is No experience, 5 is Extensive experience
Administrative & Office Worker: Experience with Excel
1
2
3
4
5
No experience
Extensive experience
1 is No experience, 5 is Extensive experience
Administrative & Office Worker: Experience with Google Workspace
1
2
3
4
5
No experience
Extensive experience
1 is No experience, 5 is Extensive experience
Administrative & Office Worker: Experience with data entry and records management
1
2
3
4
5
No experience
Extensive experience
1 is No experience, 5 is Extensive experience
Administrative & Office Worker: Experience with scheduling, phone systems, email, and customer service
1
2
3
4
5
No experience
Extensive experience
1 is No experience, 5 is Extensive experience
Documents
Government ID
*
Upload a File
Cancel
of
Diploma or GED
*
Upload a File
Cancel
of
Resume
Upload a File
Cancel
of
Certificates
Upload a File
Cancel
of
Other Required Documents
Upload a File
Cancel
of
Student Acknowledgments
I acknowledge receipt and review of the Enrollment Agreement
*
Yes
I acknowledge review of tuition and fees
*
Yes
I acknowledge review of the cancellation and refund policy
*
Yes
I acknowledge review of completion requirements
*
Yes
I acknowledge review of attendance and academic policies
*
Yes
I acknowledge review of the student complaint procedure
*
Yes
I acknowledge review of the applicable catalog and handbook
*
Yes
Certification
Certification Statement
Electronic Signature
*
Printed Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Automatic Timestamp
Internal Use Only
Received Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Program
*
Please Select
CNA
Medical Assistant
Phlebotomy
EKG Technician
Pharmacy Technician
Other
Documents Verified
*
Photo ID
Proof of Address
High School Diploma/GED
Transcript
Immunization Record
TB Test
Other
Orientation Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Start Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Cohort
Instructor
First Name
Middle Name
Last Name
Funding Status
Please Select
Self-Pay
Scholarship
Workforce Grant
Employer Sponsored
Pending
Other
Enrollment Status
*
Please Select
Pending Review
Accepted
Waitlisted
Enrolled
Deferred
Withdrawn
Denied
Other
Staff Notes
Submit
Submit
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