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STUDENT REGISTRATION FORM
31620 23rd Ave S, Suite 304 Federal Way, WA, 98003
Personal Information
First Name
*
Last Name
*
Gender
*
Male
Female
Non-binary/Other
Prefer not to say
Race (Check only one box)
*
White/Caucasian
Asian
Black/African American
Multiracial
American Indian or Alaska Native
Hawaiian Native or other Pacific Islander
Other
Are you Hispanic in origin?
*
Yes
No
Do you have a Disability?
*
Yes
No
Are you a military veteran?
*
Yes
No
Highest grade completed
*
Less than high school graduation
High school graduate
GED
Some post high school, no degree/certificate
Certificate (less than 2 years)
Associate degree
Bachelor's degree
Master's degree or higher
Do you require any special accommodations or support during your training?
*
No
Yes
If Yes, please specify:
Contact Information
Cell Phone No.
*
Email Address
*
Address
*
City
*
State
*
Zip Code
*
Course Information
Course Name (Tick one)
*
HCA
CNA (Trad)
HCA-CNA Bridge
Preferred start Date
*
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How did you hear about us?
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Signature
Student Signature
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Registration Date
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