HEALTH CAREERS TRAINING INSTITUTE - ENROLLMENT FORM

Please list Program of Interest and Month You Wish To Begin above

Today's Date *

First Name *

Last Name *

Social Security Number *

Date of Birth *

Upload a Copy of Social Security Card *

Upload Government-Issued Photo ID here (DL/State ID/Passport) *

Address

Street Address

City

State

Country

Postal code

Were you referred by a former HCTI student? if so, please list their name.

Phone *

Email *

Have you ever been convicted of a Felony? *

Referring Party/Agency

Select the Course in Which You are Enrolling? ALL Classes require $150 Application Fee or 3rd Party Agency Referral *

Upload Copy of a 2-STEP PPD/TB Skin Test result - must be within last 12 months; OR negative TB blood test OR Chest Xray - YOU WILL NOT BE ALLOWED INTO CLINICALS WITHOUT IT

Have you ever been placed on an Abuse Registry? *

Upload Copy of High School Diploma - If you do not have one, you will be required to take a Math/Reading assessment prior to acceptance into the Program

Signature of Acknowledgement/Understanding: By Signing this Application, I have read the policies on HCTI's website including the Refund and Attendance Policies. I understand that ALL fees are non-refundable. *

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Reading Assessment: If you do not submit a High School Diploma, you must successfully complete the reading assessment here and forward the results to [email protected]: English Grade 7 - Reading Comprehension Test 11

Signature of Acknowledgment/Statement of Understanding: By Signing here, I acknowledge that I have read and understand the Statement of Understanding (link here: https://api.leadconnectorhq.com/widget/form/tRDJ51TZqut678L93hkY?notrack=true *

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***You must pay a $150 Non-Refundable Application Fee in order for this application to be processed. This amount goes toward the total course cost* You may also pay the ENTIRE course amount up front by selecting "Other Amount" below***

$ 150

Other amount