Today's Date *

First Name *

Last Name *

Ethnicity *

Gender: *

Program of Study *

Cohort Date *

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? *

Have you ever been placed on an Abuse Registry? *

Were you referred? If so, select the Referring Party/Agency

Do You Require a Payment Plan? If you select "Yes" here, you MUST complete the Payment Plan Agreement form. *

Yes Payment Plan Agreement required + $50 fee

Cohort Start Date: Select the Course in Which You are Enrolling? There is a $150 Application Fee unless referred by 3rd Party Agency. *

Please indicate your t-shirt size here:

Other Uploads: *Upload a copy of a current 2-STEP TB skin test (within) 12 months of this's date. HCTI offers the 2-STEP PPD/TB Test for $50. *Certified Medication Aide applicants only- Upload a copy of Letter of Good Standing from current employer here

Do you need to schedule an appointment with HCTI to have a 2-STEP PPD?TB Test done?

Yes

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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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

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

<p><strong>Reading Assessment: </strong>If you do not submit a High School Diploma, you must successfully complete the reading assessment here and forward the results to [email protected]: <a target="_blank" rel="noopener noreferrer nofollow" href="https://englishteststore.net/index.php?option=com_content&view=article&id=15627%3Aenglish-grade-7-reading-comprehension-test-11&catid=589&Itemid=844#gsc.tab=0">English Grade 7 - Reading Comprehension Test 11</a></p>1.5Reading 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 11VerdanaParagraph14px

Signature of Acknowledgement/Refund Policy: **Please read CAREFULLY** By signing here, I acknowledge that I have read HCTI's Refund Policy which is available at https://hctiky.org/refund-policy. I understand that there is a NO REFUND policy. Any payment made including payments for application fees, tuition, payment plan payments, fees or any service/product is NON-REFUNDABLE! *

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***You must pay a $150 Non-Refundable Application Fee to process this application. This amount goes towards the total course cost* You may also pay the ENTIRE course amount up front by selecting "Other Amount" below. If you chose a Payment Plan, you must add $50=Total Due Today $200***

$ 150

$ 200

Other amount