WCSE Medical Assistant Course_

Registration Form

First Name *

Last Name *

Date of birth *

Social Security Number *

Email *

Phone Numer *

Address

Street Address *

City

State *

Country *

Country

Zip Code *

Are you a U.S. Citizen *

Select

Have you registered for a class at WCSE in the last 2 months? *

What is your CNA License Number *

Please share why you desire to become a Medical Assistant *

How did you hear about W.C.S.E.? *

Select

I own or have access to a smart phone and/or computer/laptop with internet access? *

Select

Section *

Select section

Class *

Select Class

Medical Assistant Class Start Dates *

2/23/26-

Have you been enrolled in a previous training program *

Select

Have you been terminated from a program *

Select

If you answered yes to the previous question. Please explain the reason you were terminated or unable to complete the program

Have you ever been convicted of a felony? *

Select

If you have been convicted of a felony, please explain

High School Name *

High School City & State *

Did you graduate from High School? *

Select

College/University Name

College/University City & State

Did you graduate with a college degree? *

Select

Did you receive testing accommodations or support at a previous school? *

Select

Do you have any known learning disabilities? If yes, please list them. If no, type N/A *

Please upload a copy of your ID (ex drivers license) *

Do you have a copy of your GED or High school Diploma? *

Yes

Unsure

Upload a copy of your GED or Highschool Diploma

Emergency Contact *

Emergency Contact Email *

Emergency Contact Phone *

What is your preferred tuition payment type? Note: Any adjustments to your selected plan will incur a $30 fee *

Payment in full 2 weeks before class start date

50% 2 weeks before class start date + 50% 2 weeks before last day of class

$400 down and $600/weekly weeks 2-6)

You may be eligible for financial aid if you are experiencing one or more of the following: *

You are low income

You are recieving SSI

You are recieving disability

You are currently homeless

You are in a foster care or recently aged out of foster care

You are a woman over 21 and have had at least 24 consecutive months as a non- student

None of the above apply to me

Confirmation & Signature (Typing your full name below certifies your consent and agreement) *

I certify that my answers on this document are true and complete to the best of my knowledge. If I am accepted into the Institute, I understand that any false or misleading information contained in my application or interview, regardless of the time of discovery, may result in my dismissal from the program. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent to references and former employers and educational institutions listed being contacted.

Student Acknowledgment Statement:

I understand that the registration fee is a non-refundable administrative fee.

I understand that payment of the registration fee does not guarantee or affect my placement in the course, and that placement is determined separately. By checking both boxes, I acknowledge and agree to these terms before submitting my payment.

Collect Payment *

$ 50

*100% secure & safe payments*