* = Required Information
Please checked preferred campus:
Emergency Contact Name:
Education: Number of years (circle one) College
Name of High School Attended:
Do you have a high school Diploma or G.E.D.?
If NO did you complete 12th grade?
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?
If yes, Name & Address:
Have you been convicted by any agency of child, patient resident or elderly abuse?
Have you ever been convicted of a felony?
How did you hear about us?
Start date of Class:
NA Refresher Course
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.
REGISTRATION FEE: $30.00 (NON REFUNDABLE)
STUDENT INTERVIEW FORM
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?