Enrollment Application

Healthcare and Training Institute

A Legacy Of Excellence

Full Name(Required)

First Last

Social Security Number(Required)

Date of Birth(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you 18 years or older?(Required)

Yes

Education

High School(Required)

Date of Graduation

Date GED Certification Awarded

List any colleges or other schools you attended after High School: School Area of Study or Major Dates Attended/Graduated

Employment

Present Employer

Job Title

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Hours

Job Responsibilities

Please be advised that employment in the health care field may require a police background check and/or drug testing. Please discuss in a short paragraph your reasons for applying to this program. Include any health-related experience you may have had.(Required)

I am here by enrolling in one of the courses with Hands of Angels Healthcare & Training Institute LLC and my enrollment is subject to the terms and conditions stated in this enrollment agreement. Financial aid and placement assistance is not available for this class.

Program Name

Start Date

Program Information

Course Start Date

Class Programs(Required)

Total

Required Documents

Social Security Card

Max. file size: 128 MB.

Government ID

Max. file size: 128 MB.

Government ID 2

Max. file size: 128 MB.

Signature