Fast Track AMP Grant Application

Fast Track Program Application

Complete the enrollment application with your personal, program, grant eligibility, and signature details.
Student Information
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number

Area CodePhone Number
Email Address
example@example.com
How do you prefer to be contacted?
Program Selection, Grant Eligibility, and Consent to Share Information
Select Your Program
Which program are you interested in? You may select more than one.
Select Your Location
Where would you attend skills (in-person)?
How did you hear about our programs?
Which Adult Education program or brochure?
Entrance Requirements
Please briefly describe your current or recent patient-facing role in healthcare.
Tell us about your experience in the field- even if you think it may not qualify. This experience does not have to be in the state of Maine.
Consent to Share Information
Program Agreements
Fast Track Program Policies and Information
Can't view the Program Policies Document? Right click here and select open in new window to download the PDF directly.
Upload Immunizations/Resume here. Don't have them yet? You may also email, fax or upload by following the link in the confirmation email once you submit this form.

Cancelof
Immunizations and Program Attestations
Policies Agreement
Enrollment Agreement
Social Security Number
Student Signature
Print Full Legal Name

First NameMiddle NameLast NameSuffix
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Questions or Notes for Admissions
Type your questions here!
Administrative Use Only
Date Application Received

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Processed By
Student ID #
Program Confirmed
Payment Confirmed
Start Date Confirmed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Funding Source Verified
Internal Notes
Should be Empty:

Fast Track Program Application

Student Information

Program Selection, Grant Eligibility, and Consent to Share Information

Program Agreements

Administrative Use Only