Registration for other Courses

Select Campus

Place checkmark (√) next to program of interest

Certified Nurse Assistant

Home Health Aide

Patient Care Technician

Phlebotomy Technician

Telemetry Technician

Session

Session Start Date

Your Name

Other name (if applicable)

Date of Birth

Gender

Male

Female

SS#

City

State

Zip

Phone #

Alternate #

Email

Name

In case of emergency please notify:

Phone #

Relationship

Have you ever been convicted of a crime, misdemeanor, or felony?

Yes

No

If yes, please explain

Ethnic Background (optional)

Asian or Pacific Islander

Black, Non-Hispanic

Hispanic

Native American or Alaskan Native

Citizenship Status

US Citizen

Permanent resident or Resident Alien (provide Alien Registration Card, form 1-551)

Refugee or asylum status (provide proof of status from USCIS)

My education level is:

Still attending high school (requires High School’s authorization, see below)

High School graduate or GED

Non-high school graduate

Associate Degree or less

More than 2 years, but less than 4 years

Four-year college graduate

More than four years of college

Name of High School

City

State

Year(s) attended

Year graduated

GED year completed

Name of High School

*THIS SECTION TO BE COMPLETED IF CANDIDATE IS STILL IN HIGH SCHOOL*

City

State

Authorizing Agent

Title

Date

REFUND AND RETURN POLICY:
The $40 application fee is non-refundable. Tuition is non-refundable if the student withdraws after the first day of the course has commenced. Tuition is only refundable if the applicant notifies Serenity Health Training Institute of his/her wish to withdraw, in writing, no later than seven (7) calendar days before the first day the course is scheduled to begin, and/or if the applicant is rejected by Serenity Health Training Institute, or for failure to meet any and all applicable requirements and state protocol under Michigan law.
If an applicant has not attended a class and notifies the school Seven (7) calender days prior to start of the session tuition will be fully refunded less the application non-refundable application fee. Qualifying refunds will be available Thirty (30) calendar days from the date the written request was received. No refunds will be granted after a student has attended the first day of class for the session.

Your Name

Date

Signature

Payment

USD $250

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