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PERSONAL INFORMATION

Please checked preferred campus:

Charlotte

Gastonia

Name

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Last

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First

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Middle Initial

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City

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State

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Zip

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Phone #

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Cell

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Email Address

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Emergency Contact Name

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Relationship

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Phone #

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Education: Number of years (circle one) College

Name of High School Attended

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Address

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

Yes

If NO did you complete 12th grade?

Yes

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

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List of any other educational experience

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Are you currently in school?

Yes

If yes, Name & Address

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

Yes

Have you ever been convicted of a felony?

Yes

How did you hear about us?

Referral

Website

Flyer

Check One:

Day

Evening

Weekend

Start Date of Class

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CNA1

CNA II

Med Aide

Pharmacy Technician

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

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Date

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REGISTRATION FEE: $45.00 (NON REFUNDABLE)

STUDENT INTERVIEW FORM

Student Name

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Date

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

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

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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?

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

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

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Applicant Signature

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Date

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Name on Card

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Expiry Date

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Security Code

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