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

Upload a Copy of Social Security Card *

Address

Street Address

City

State

Country

Postal code

Phone *

Email *

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

Referring Party/Agency

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

Have you ever been convicted of a Felony? *

Have you ever been placed on an Abuse Registry? *

Upload Copy of TB Skin Test resut - must be within last 12 months or Chest Xray

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. I understand that ALL fees are non-refundable. *

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*You must pay a $150 Non-Refundable Application Fee. This amount goes toward the total course cost

$ 150