Language
English (US)
Somali
Nursing Admissions Application
Name
*
First Name
Middle Initial
Last Name
Birth Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Male
Female
Decline to Answer
Are you Hispanic or Latino?
*
No
Yes
Decline to Answer
Race:
*
American Indian/Alaskan Native
Asian
Black
Native Hawaiian/Other Pacific Islander
White
Decline to Answer
Highest level of education completed
*
High school diploma
GED
Associates Degree
Bachelors Degree
Masters Degree
Some College
Still in high school
Emergency Contacts (please list at least 2 contacts that can be reachable in case of an emergency include name, relation to you and phone number)
*
Do you have a current AHA Basic Life Support CPR card? We offer this class as well.
Yes
No
I'm not sure
Certification must be through American Heart Association (AHA)
Is English your first language? Are you willing to complete our basic English test?
Yes
No
Students must be proficient in the English language in order to be successful in the program.
Of which country are you a citizen?
*
Select Country
United States
Afghanistan
Albania
Algeria
American Samoa
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaidjan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia-Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia, Kingdom of
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
Former Czechoslovakia
Former USSR
France
France (European Territory)
French Guyana
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada
Guadeloupe (French)
Guam (USA)
Guatemala
Guinea
Guinea Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast (Cote D'Ivoire)
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyz Republic (Kyrgyzstan)
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique (French)
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldavia
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
Neutral Zone
New Caledonia (French)
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Island
Poland
Polynesia (French)
Portugal
Puerto Rico
Qatar
Reunion (French)
Romania
Russian Federation
Rwanda
S. Georgia & S. Sandwich Isls.
Saint Helena
Saint Kitts & Nevis Anguilla
Saint Lucia
Saint Pierre and Miquelon
Saint Tome (Sao Tome) and Principe
Saint Vincent & Grenadines
Samoa
San Marino
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syria
Tadjikistan
Taiwan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
USA Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (USA)
Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Are you able to legally work in the U.S.
*
Yes
No
Phone
*
-
Area Code
Phone Number
E-mail Address
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Back
Next
Application Fee
Tuition includes the background study clearance fee, finger printing, textbook/workbook and lab fees. If a third party entity is paying the tuition on behalf of the student, please check the "other" box and provide 3rd party payee name and contact number. Please keep in mind that our program is WIOA certified to receive funding from county programs. Please send us an email to nursing@primetimemedtraining.com to request tuition assistance options.
Payment Method:
*
Credit Card
Mail a Check
In-person at school
Are you at least 16 years of age? You must be at least 16 years old to enroll
*
yes
No
Which Cohort are you applying for?
*
Day (9am-2pm)
Evening (5pm-10pm)
E/O Weekend (Sat & Sun 9am-4:30pm)
Tell us why you want to pursue a career as a nursing assistant/home health aide
*
Scrub Top Uniform Order
Small
Medium
Large
Extra Large
This section is optional if you plan to order the school uniform from us. Our program uniform is red scrub top with black scrub bottoms. Add $50 to tuition cost. This will be invoiced separately.
Scrub Bottom Uniform Order
Small
Medium
Large
Extra Large
This section is optional if you plan to order the school uniform from us. Our program uniform is red scrub top with black scrub bottoms. Add $50 to tuition cost. This will be invoiced separately.
How did you find out about us?
*
If referred by someone, please provide full name of referring individual
Application Fee/Tuition Payment terms
*
prev
next
( X )
USD
The Nursing Assistant tuition is $775 plus $200 for the NATO state exam fee totaling $975. The Application fee as part of the tuition is $50. Applicants must pay the $200 deposit and the $50 application fee to reserve their seat in the nursing assistant cohort within 7 business days of being notified of application approval. If student is having a 3rd party agency cover their tuition cost, the submittal of a payment authorization from said 3rd party payee must be emailed to nursing@primetimemedtraining.com or uploaded to this application using the upload section. If the student fails to submit the $250 within said time frame, they will forfeit their seat into the program and their start date may be postponed. $150 out of the $200 deposit is non-refundable once application is approved and student has accepted their seat. Costs for student program uniform, Basic Life Support CPR training is an optional add on. If a student indicates on their application that they do not have a current Basic Life Support certification, the school will automatically add this training to the student’s tuition at a promotional rate of $50. If the student indicates that they would like to purchase program uniform through our school, an additional $50 will also be added to their tuition cost, otherwise the student will be responsible for the purchase of their program uniform. Uniform colors are red scrub top with black scrub bottoms. Please keep in mind that once a uniform has been issued to student, it is non-refundable. Once a certification has been issued the training for that course is non-refundable. Once a student starts the program, they forfeit their eligibility for a refund. Applicants going through a third party pay source shall notify school as other payment arrangements can be made but must be submitted and approved in writing.
Payment terms on how I want to pay my tuition
Pay in full
Pay with 2 installments
Pay in 3 installments
These terms are not final, if choosing a payment plan, you will receive a payment invoice and be contacted to enroll in auto payment drafting to pay your invoice as scheduled per your payment arrangement. All payment arrangements must be paid in full before any clinical hours.
By signing below, you are acknowledging that you agree to have read the information in this application in its entirety. You also acknowledge that you are the student enrolling or delegated designee to complete this application. By signing this application form, you are agreeing and acknowledging understanding of the terms and agreements set forth in this document and take full responsibility for the payment of the tuition and fees for the program you are applying to.
Submit Form
Clear Form
Print Form
Should be Empty: