GENERAL ENROLLMENT APPLICATION

Today's Date *

First Name

Last Name

Ethnicity *

Select your Preferred Cohort Start month. *

Gender: *

Social Security Number *

Date of Birth *

Upload a Copy of Social Security Card *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Upload Government-Issued Photo ID here (DL/State ID/Passport) *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Address

Street Address

City

State

Country

Postal Code

Phone *

Email *

Emergency Contact Name

Emergency Contact Phone Number

Have you ever been convicted of a Felony? *

Have you ever been convicted of, pleaded guilty to, or entered a plea of no contest to offenses involving abuse, neglect, exploitation, theft, fraud, violence, sexual misconduct, or controlled substances? *

Have you ever been listed on an abuse registry? *

Do you have a GED or high school diploma? *

Upload a Copy of Your High School Diploma or GED:

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Reading Assessment:
If you do not submit a high school diploma or equivalent, you must successfully complete the English Grade 7 – Reading Comprehension Test 11 and forward your results to [email protected].

Were you referred by a third party or agency? If yes, please select the referring party or agency from the list below.

Do you require a payment plan? *

Yes Payment Plan Agreement required. If you select yes, you are required to complete the Payment Plan Agreement below

Select Payment Plan. ALL Payment Plan require a $50 fee to be paid with this application fee. ALL Payment Plan initial payments begin 10 days prior to the start of class and continue weekly according to the schedule below. Failure to pay as agreed below will result in cancelation of your course. *

Digital Signature *

Clear

By signing here, I acknowledge that failure to pay as agreed per the selected payment agreement will result in cancelation of my course and I will not be entitled to refund of any amount paid. I will continue to owe any unpaid balance and will be subject to any/all collections procedures allowed under Kentucky law.

Please indicate your t-shirt size here:

Other Uploads: 1). 1) 1) Please upload a copy of your current 2-Step TB Skin Test (completed within the past 12 months). HCTI offers the 2-Step PPD/TB Test for $50. 2) For Certified Medication Aide (CMA-I and CMA-II) Applicants Only: Please upload a copy of your Letter of Good Standing from your current employer. You may upload the document here.

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

For CMA-I and CMA-II Students Only: Please provide the name and address of your current employer.

Would you like to schedule an appointment with HCTI to complete your 2-Step PPD/TB Test? *

Yes

Acknowledgement & Refund Policy Agreement: By signing below, I acknowledge that I have read and understand HCTI’s Refund Policy, available at https://hctiky.org/refund-policy. I understand and agree that all payments are non-refundable, including but not limited to application fees, tuition payments, payment plan installments, and any other fees, services, or products purchased. *

Clear

Acknowledgement of KCPE Complaint Process: By signing below, I acknowledge that I have been informed of the complaint process through the Kentucky Commission on Proprietary Education. I understand that if I am unable to resolve an issue with Health Careers Training Institute, I may file a complaint by submitting a completed “Form to File a Complaint” (PE-24) to the Commission at the address listed above. I understand that the complaint form is available at: http://www.kcpe.ky.gov/forms/FormtoFileaComplaint.pdf *

Clear

Acknowledgement of the Existence of the Kentucky Student Protection Fund: By signing below, I acknowledge that I have been informed of the existence of the Kentucky Student Protection Fund pursuant to KRS 165A.450. I understand that licensed schools are required to contribute to this fund, which may provide reimbursement to eligible Kentucky students for certain financial losses resulting from a school closure, program discontinuance, loss of licensure, or loss of accreditation, subject to applicable eligibility requirements. *

Clear

Acknowledgement of Student Protection Fund Information: By signing below, I acknowledge that I have received and reviewed the information regarding the process for filing a claim against the Kentucky Student Protection Fund. I understand that claims must be submitted using Form PE-38 to the Kentucky Commission on Proprietary Education at the address provided above. I understand that additional information and the claim form are available at: https://kcpe.ky.gov/Pages/Student-Protection-Fund.aspx (copy) (copy) *

Clear

Acknowledgement of Receipt/Review - Statement of Understanding: By signing below, I acknowledge that I have received and reviewed the information regarding the Statement of Understanding which is available for review here: https://drive.google.com/file/d/15YmKIrJOwOfKAulvGDYtOqepcJ_0AIo3/view?usp=drive_link *

Clear

A non-refundable $150 application fee is required to process your application. This fee will be applied toward your total course tuition. You may also choose to pay the full course tuition upfront by selecting “Other Amount” below. If you select a payment plan, an additional $50 payment-plan fee will be added, making your total due today $200.

$ 150

$ 200

Other amount