Home Health Aide - 1st Choice CC Application

Date

First Name

Last Name

Phone

Address

Address Line 1

Address Line 2

City

Country

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State/Province

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Zip Code

Date of Birth

Last 4 of Social Security Number

What is the name of the High School you attended?

School Address

Highest Level of High School Completed

Month and Date of Graduation if applicable

Emergency Contact

First Name

Last Name

Phone

Relationship

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Add

Home Health Aide Enrollment Criteria

Be at least 16 years of age
Submit a Photo ID and Social Security Card
Proficiency in English reading, writing, and comprehension at an 8 th grade level

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By checking below, I confirm I meet the enrollment criteria above.

I confirm

Refund Policy School Catalog

Review Refund and School Policy by clicking the above links

Acknowledge of Refund and School Policy

Checkbox Description

I understand and agree of school's refund policy and polices listed in the student catalog above Print or save for your records

Signature

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Billing Address

Address Line 1

Address Line 2

City

Country

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State/Province

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Zip Code

Sub Total

$225.00

TOTAL

$225.00

Payment Method

1st Choice Career Centers

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