• CHHA Student Registration Form

  • Date of birth*
     - -
  • Format: (000) 000-0000.
  • Gender*

  • Emergency Contact

  • Format: (000) 000-0000.
  • Do you have any responsibilities that may interfere with this program?*

  • If yes, specify *

  • Where did you hear about the school?*
  • Have you ever been convicted of a criminal act?*

  • If yes, specify *

  • Have you applied for a HHA License before?*

  • Signature: I have authorized Elderly Savior Homecare to perform a criminal background
    check. I certify that, to the best of my knowledge and belief, all of my statements are true,
    correct, and complete. I understand that any false or incomplete statements are grounds
    for denial of admission or dismissal from Elderly Savior Homecare without a complete or
    partial refund.

  • Date*
     - -

  • Reminder:

    To get started, please pay the $100 registration fee to reserve your spot and complete the registration form. After that, you can choose the payment plan that works best for you and select your preferred payment method.
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