Clone of Phlebotomy Enrollment Form

Medication Aide Enrollment Form
Student Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Social Security Number*
Required for background check screening
Race*
Required for background check screening
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail*
example@example.com
Mobile Number*
Education/Enrollment
Do you have a high school diploma or GED?*

YesNoStill in high school
Are you at least 18 years old?*

YesNo
Are you a veteran?*

YesNo
Do you currently receive SNAP/TANF benefits?*

YesNo
Are you currently employed?*

YesNo
If employed, where? If no, enter N/A*
Are you currently in the medical field?*

YesNo
If yes, which certification do you have?

HHA (Home Health Aide)CNA (Certified Nurse Aide)QMA (Qualified Medication Aide)MA (Medical Assistant)N/AOther
How did you hear about Essential Healthcare Academy?

Family/FriendSocial MediaCurrent/Previous StudentGoogle SearchCommunity EventEmployerFWCS Adult Ed.
Please select the class you would like to attend:*
*Registration will close 1 week prior to class start date.
Please select required orientation date that corresponds with the class you will be enrolled in.*
Orientation is required.
What size scrubs do you wear?*
How will you be paying for the cost of the program?*
Does Essential Healthcare Academy permission to contact you?

YesNo
Please upload a copy of your state issued ID. (Additional documents will be needed prior to start date).**

Cancelof
By signing below I certify that all answers given in this application are accurate to the best of my knowledge. I understand that failure to disclose or falsifying information could result in my dismissal from any course.
Signature

Clear
Registration Fee - Please do not complete this form until you have been approved for funding OR unless you are self pay.*

Registration Fee is non-refundable and non-transferrable.

My Products*

Medication Aide (QMA)4% online processing fee will be applied

$100.00

Insulin

$225.00 Quantity

State Exam Review

$200.00 Quantity

Enter coupon

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

Should be Empty:

Medication Aide Enrollment Form

Payment Methods