$1000 Scholarship

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Program of Interest* This field is required.
Please Select
Please Select
Drug & Alcohol Counseling (DAC)
Pharmacy Technician (Rx)
Administrative Medical Assistant (AMA)
Clinical Medical Assistant (CMA)
Clinical & Administrative Medical Assistant (CAMA)
Medical Billing & Coding (MBC)
5
Campus of Interest* This field is required.
Please Select
Please Select
Ontario
Santa Ana
Temecula
6
City of Residence* This field is required.
7
You may qualify for a grant. Please select all that apply* This field is required.
I am between the ages of 18 and 24
I am between the ages of 25 and 28
I am older than 28
I'm unemployed
I'm underemployed (working less than 20 hours/week)
I'm a Displaced Worker (Laid Off/Fired/Quit)
I'm a low-income family
I'm receiving unemployment insurance
None of the above
Should be Empty: