Application

Application
Application Date

MonthDayYear
Date
Contact Information
Applicants Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What program are you interested in?
Personal Information
Are you 17 years of age or older?
Date of Birth

MonthDayYear
Date
Social Security Number
Submit a copy of your Social Security Card

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Drivers License Number
Driver License State of Issue
Submit a copy of your Driver License

Cancelof
Emergency Contact Information
Emergency Contact

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email Address
example@example.com
Education
Do you have your High School Diploma or GED
Submit a copy of your High school Diploma or GED

Cancelof
If you DO NOT have a Diploma or GED, can you read/comprehend at a 7th grade level?
Background
Have you ever been placed on the Abuse Registry
Have you ever been convicted of a Felony?
If you answer "Yes" or "Unsure" to any of the above questions in the Background section. Please provide a brief explanation.
When would you like to start classes?
Why do you want to be in the medical field?
Disclosures

Please read these disclosure(s) carefully, then initial and sign where requested.
Withdrawal

Withdrawal from class must be requested in writing and is not official until the administration receives the letter. Mail to: Healthcare Essentials Training Institute, 3135 Commerce Center Place, Louisville, KY 40211. A withdrawal does not cancel the student's financial obligation. Please know it is your responsibility to ensure we have your most up to date address on file. Students will be recorded as 'release from the program' upon withdrawal.
Initial here that you understand the withdrawal disclosure
Dismissal

Students will be counseled on behavioral issues and code of conduct violations twice prior to dismissal from the program. All counseling sessions will be conducted by the program coordinator in person and will be documented via progress report in the students file.

In case of program dismissal from the program for inappropriate behavior, unsafe practices, or consistently violating school policy, the student will be made aware of the violated policy / code of conduct and removed from the program immediately.
Initial here that you understand the dismissal disclosure
Payment Schedule

Paid in Full - Students may pay in full for any of our training programs. We accept the following forms of payment: Paypal, Zell, Cashapp, cash, money order, certified funds check, credit card, or debit card. No personal checks will be accepted.

Payment Plan - Students may be given the option to engage in a payment plan, however payment in full is required prior to the start of classes. All students engaged in a payment plan must sign the Tuition Payment Plan Agreement From. The agreement form will outline your payment structure and all payments will be recorded on this form.
Initial here that you understand the payment schedule.
Late Payments and Refunds

Late Payments

Tuition must be paid in full prior to the start of class unless you are using the payment plan option.

Refunds

All fees are non-refundable
Initial here that you understand the late payment and Refund disclosure
Re-Entry

Any student who has been Dismissed from the program WILL NOT be allowed to re-enter the training program.

Students who withdraw from the program on their own accord will be able to re-enter the program during the next program offering or future offering if they choose. The student will have to pay the application fee again but will not have to have an additional background check if conducted within 60 days.

Students who fail the training program may attempt the program again one more time. However, the student may only attempt the same training program twice. After two attempts the student will not be able to re-enroll in the Healthcare Essentials Training Institute program again.
Initial here that you understand the re-entry disclosure
Grievance

All grievances must be submitted in writing to the Administration:

Melissa Coleman or Lisa Walton

3135 Commerce Center Place

Louisville, KY 40211

The administrative staff must follow up on the grievance within 24 hours or 1 business day of the grievance being submitted for investigation. The program coordinator will interview all parties involved and make a determination. The student will receive a final answer regarding the grievance within 3 business days from the data the grievance was submitted for investigation. Students should attempt to resolve all issues with the school or its instructors' promptly.
Initial here that you understand the grievance disclosure
Filling a Complaint with the Kentucky Commission on Proprietary Education

If a student is unable to resolve any issues with Healthcare Essentials Training Institute, They may file a complaint with the Kentucky Commission on Proprietary Education. Each person filing must submit a completed "Form to File a Complaint" (PE-24) to the Kentucky Commission by mail to:

Kentucky Commission on Proprietary Education

500 Mero street

Frankfort, KY 40601

This form cam be found here: http://www.kcpe.ky.gov/forms/FormtoFileaComplaint.pdf

Existence of the Kentucky Student Protection Fund

Pursuant to KRS 165A.450 All licensed schools, resident and non-resident, shall be required to contribute to a student protection fund. The fund shall be used reimbursed eligible Kentucky students, to pay off debts, included refunds to student enrolled or on leave of absence by not being enrolled for one (1) academic year or less from the school at the time of the closing, incurred due to the closing of a school, discontinuance of a program, loss of license or loss of accreditation by a school or program.

Process for filing a Claim Against The student Protection Fund

To file a claim against the Kentucky Protection Fund, each person filing must submit a signed and completed Form for Claims Against the Student Protection Fund, Form PE-38 and provide the requested information to the following address:

Kentucky Commission on Proprietary Education

500 Mero Street, 4th floor

Frankfort, KY 40601

The form can be found here: https://kcpe.ky.gov/Pages/Student-Protection-Fund.aspx
Initial here that you understand the compliant process for the Kentucky Commission of Proprietary Education
I certify that I have received a copy, read and understand the information above with regards to enrolling into the state registered program with Healthcare Essentials Training Institute.
Please sign here if you agree to all the terms in this document.

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Application

Contact Information

Personal Information

Emergency Contact Information

Education

Background

Disclosures

Withdrawal

Dismissal

Payment Schedule

Late Payments and Refunds

Re-Entry

Grievance

Filling a Complaint with the Kentucky Commission on Proprietary Education

Existence of the Kentucky Student Protection Fund

Process for filing a Claim Against The student Protection Fund

I certify that I have received a copy, read and understand the information above with regards to enrolling into the state registered program with Healthcare Essentials Training Institute.

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