Victorious Healthcare Academy Registration Form

Student Registration Form

Name*

First Name, M.I.Last Name

Street Address*

Apartment Number

City*

State*

Zip Code*

Apartment*

Phone Number*

Please enter a valid phone number.

E-mail address*

example@example.com

Gender*

Date of birth*

Are you a U.S. Citizen?*

Which location are you registering for?

Course Interest *

Why are you interested in registering for this class?*

Have you ever been convicted of a felony?*

If yes, please explain.*

Highest Grade Completed*

City & State*

Graduation Date*

Date

Graduation Date*

Date

City & State*

Current Employer*

What is your current job title?*

Emergency contact Phone Number*

Please enter a valid phone number.

Emergency contact*

First NameLast Name

*NON REFUNDABLE REGISTRATION APPLICATION FEE OF $25.00 REQUIRED TO PROCESS THIS APPLICATION. I am an authorized user of the card entered to pay the NONREFUNDABLE registration fee and will NOT dispute the payment with my credit/debit card institution; so as long as the transaction corresponds to the terms indicated in this form (Please type OK and YOUR NAME in the box below)*

Application Fee*

Application Fee

$25.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

I certify that my answers on this document are true and complete to the best of my knowledge. If I am accepted into the Institute, I understand that any false or misleading information contained in my application or interview, regardless of time of discovery, may result in my dismissal from the program. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent to references and former employers and educational institutions listed being contacted.

Printed Name of Student*

Signature*