Enrollment Form

Please checked preferred campus:

Charlotte

Gastonia

Name *

Last *

First *

Middle Initial

City *

State *

Zip *

Phone # *

Cell *

Email Address *

Emergency Contact Name *

Relationship

Phone #

Education: Number of years (circle one) College

8

9

10

11

12

13

14

15

16

Name of High School Attended:

Address:

Do you have a high school Diploma or G.E.D.?

Yes

No

If NO did you complete 12th grade?

Yes

No

Please provide a copy of School Diploma or Transcript.
In absence of high school Diploma, student is required to take a placement test (T.A.B.E. -Math computation, Applied Math and Reading.

TABE test score:

List of any other educational experience:

Are you currently in school?

Yes

No

If yes, Name & Address:

Have you been convicted by any agency of child, patient resident or elderly abuse?

Yes

No

Have you ever been convicted of a felony?

Yes

No

How did you hear about us?

Referral

Website

Flyer

Check One:

Day

Evening

Weekend

Start date of Class:

Medication Aide

CPR

NA1

I certify that the information provided in this application is true and complete to the best of my knowledge. I agree that if I misrepresent or omit any relevant information or provide false answers, Umanah Healthcare Institute will disqualify or discharge me from the Program without any refund.

Applicant Signature:

Date:

REGISTRATION FEE: $45.00 (NON REFUNDABLE)

STUDENT INTERVIEW FORM

Student Name:

Date:

1. What do you think it takes to be a good person?

2. What are (3) three words your friend would use to describe you?

3. Give me an example of a time when you had to learn something new i.e. task, or procedure. How did you learn the new task or procedure?

4. Describe your best learning experience. What made the experience a good one?

5. What are your career goals in 3-5 years?

Applicant Signature:

Date: