Patient Care Tech Registration Form

STOP! If you are using SNAP or any program where you will not be paying for your course please visit our Tuition Assistance Page and apply from there.

Which 12 Week Patient Care Technician Class Are You Interested in Attending? *

August 18, 2024-November 8, 2024
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First Name *

Middle Name

Last Name *

Maiden Name (If Applicable)

Date of birth *

Gender *

Male

Female

Address *

City *

State *

Postal code *

Email *

Phone *

Please upload a copy of your state or government issued ID, Social Security Card or Work Visa, proof of covid vaccination and any other enrollment documents. If you are not able to upload them, please bring the documents with you on Mandatory Orientation day.

Have you received the Covid Vaccination? *

Yes

No

Do you have proof of your Covid Vaccination? *

Yes

No

Do you have documentation of a medical or religious exemption for the Covid Vaccination? *

Yes

No

Are you a citizen of the United States? *

Yes

No

Are you at least 18 years of age? *

Yes

No

Driver's License Number (no dashes) *

Social Security Number *

Race (Required for Background Check *

African-American
Asian
Caucasian
Hispanic/Latino
Native American
Pacific Islander
Mixed Race
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State of Birth (Required for Background Check) *

Country of Birth (Required for Background Check) *

Which Social Media platform do you use most often? *

Facebook
Instagram
Twitter
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Have you ever been convicted of a felony or any other crime? *

Yes

No

If yes, please include specific information including the date of felony charge, nature of felony, which court and final outcome. Submit copies of the court documentation is available

Court Documentation

Did you obtain a GED or equivalent education? *

Yes

No

Did you graduate from high school? *

Yes

No

Did you graduate from college? *

Yes

No

Not Applicable

Do you have a learning disability, IEP or 504 Plan? (This will allow us to assist you during the course) *

Yes

No

Please explain, if applicable

Do you have any physical condition(s) or any other condition(s) which would limit your ability to perform essential job-related functions? *

Yes

No

If yes, specify those restrictions or accommodations

Why are you enrolling in the Patient Care Tech Program? *

How did you hear about Revived Medical Training Academy? *

Social Media
A Friend
A Relative
SNAP
Other
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What size top do you wear? *

Small
Medium
Large
XL
2X
3X
4X
5X
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What size bottom do you wear? *

Small
Medium
Large
XL
2x
3x
4x
5x
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Emergency Contact Information

Emergency Contact Name *

Mobile Phone *