SIAHT Registration form for Programs

SKOKIE INSTITUTE OF ALLIED HEALTH AND TECHNOLOGY(SIAHT) Programs Registration Form

2700 Patriot Blvd, Suite: 250, Glenview ,IL 60026 Phone: (847)461-3985 Fax:(847)561-0463 https://www.siaht.org
This registration form is a requirement in the admission process. This is the first step in getting admission for our online programs. Once student calls and talks to an admission team member, they are directed to fill out the registration form.The fees has been waived due to our promotion therefore student is directed to fill out and complete the enrollment agremeent.
A-Date of Admission *

Month Day Year Hour Minutes AM/PM Option
B-Student Name (First, Last) *

First Name Last Name
C-Student Address *

Street Address

Apt/ No.

City State / Province

Postal / Zip Code Country
D-Student Social Security Number *
Enter your S.S number
E-Student Date of Birth *

Month Day Year
F-Student Phone Number *

Area Code Phone Number
G-Student Cell number *

Area Code Phone Number
H-Student E-mail: *
example@example.com (please provide with an email that you want the school to use for LMS registration and communication purposes).
I-Student Alternate Email *
J-Marital Status *

Single Married Widowed Divorced Separated Refuse to Disclose
K-Gender *

Male Female Disagree to Disclose the Gender
L-Race *

White African American Hispanic Asian/Pacific Islander Native American Disagree to Disclose
M-Name and Address of High school. *
Please Indicate Name, Address and State of High school.
N-High School Graduation Year:

Month Day Year
Date
O-Are you working? *

Yes No
P-Name and Place of Employment:
If you are not working please put NA
Q-If working how many hours do you do on a regular basis? *

Full time-40 hrs a week Full time-30-35 hrs a week Part time- 20-25 hrs a week Part time-15-20 hrs a week I am not working at the moment Stay-at-home parent/guardian
R-Important Part of the Application:

The student applying for the programs is also required to fax a copy of their ID/DL, copy of high school diploma, transcripts and/or resume at: (847)510-0463.

These are required as a part of admission process. Student needs to email our admissions team at: admin@siaht.org or/and belashoab@gmail.com so they are aware and on the look out for your confidential information.

Once the application is submitted, student is required to fax the documents within 48 hours.

The registration fees is included during registration process unless their is a promotion the staff will let the prospect know.
S: Please select ONLY One Program you are enrolling for? *

A-Personal Fitness Trainer B-Nutrition/Wellness Coach C-Medical Billing and Insurance Specialist D-Neurology Technician E-Pharmacy Technician
Sa-Please chose your options for paying for the program once you have been accepted: *

A-WIOA applicant and will be paying via WIOA B-Payment Plan that will be discussed and agreed between Executive Director and student. C-Through Credit card/other form(check,cash, pay pal) D-Applying for scholarship and got approved E-Applying and paying through Climb Credit
Ta-Are you currently or have you ever been charged with or subject to disciplinary action for scholastic or any other type of misconduct at any educational institution? * *
Tb-If answered Yes above, Please Explain
Ua- Are you currently or have you ever been charged with a felony/criminal conduct? *
Ub-If answered Yes above, Please Explain
V-What are your future plans? *
What is your future career goals.
W-As a student I understand the following terms and conditions:
Student ID Photo: The purpose is to have a picture of the student for the School ID. You will be provided with a school ID once you have been registered in our programs. *
Referral Process: Please indicate below:
How Did you hear about us? *

Referral Website Search Social Media/Advertisement Admission Team Referral Other
I understand that the institution is required to collect my sensitive information as a part of registration process. *

Clear
Registration in the program and in institution is not complete until the Registration fees is paid. Please proceed to paying and completing the registration fees.

As stated the Registration fees is non-refundable.
Y-Programs Registration Fees *
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Registration Fee (Required) $ 40.00
Registration for programs
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SKOKIE INSTITUTE OF ALLIED HEALTH AND TECHNOLOGY(SIAHT) Programs Registration Form