Caring Hearts Health Care Admission Sheet
Name:__________________ Date:__________________
Address:_______________ SS #:__________________
___________________ DOB:__________________
Phone: ___-___-____ DL #: _________________
Cell: ___-___-____ SEX: MALE __ FEMALE
Contact Person
Name: ____________________ Phone: ___ - ___ - ___
Address:____________________ Cell: _______________
Address:____________________________________________
Please check your choice of class times: AM 9a-3p___ 4p-10p___ 5:30p-9:30p___
What is your highest level of education? 7 8 9 10 11 12 13 14 AD BS
What month will you be attending? 1 2 3 4 5 6 7 8 9 10 11 12
How did you hear about Caring Hearts Health Care? __ newspaper ad
__ friend __ craigslist __online on Ohio list of training schools
In order to understand the material included in the course you must be able read and write the English language fluently.
You must complete TB testing and BCI background check prior to attending clinical.
Tuition must be paid in full prior to attending classes with exception of students using our POP (payment option plan).
Students signature ____________________
