GENERAL ENROLLMENT APPLICATION

Today's Date *

First Name *

Last Name *

Ethnicity *

Gender: *

Select your Preferred Cohort Start month. A $150 application fee applies unless referred by a third-party agency. *

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 and Phone Number

Please list an Emergency Contact and Phone Number

Have you ever been convicted of a Felony? *

Have you ever been convicted of, pleaded guilty to, or entered a plea of nolo contendere (“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: If you do not have a high school diploma or equivalent credential, you will be required to complete a math and reading assessment prior to acceptance into the program.

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? If you select “Yes,” you will be required to complete the Payment Plan Agreement form. *

Yes Payment Plan Agreement required.

Please indicate your t-shirt size here:

Other Uploads: 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. 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

Signature of Acknowledgment/Statement of Understanding: By Signing here, I acknowledge that I have read and understand the Statement of Understanding. *

Clear

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. *

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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 *

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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. *

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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) *

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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