Text Box: Please fill out the application in full. Race is required in order for OSBI to do a background check!

If yes, please briefly explain:

 

HAVE YOU EVER BEEN CONVICTED OF A FELONY?  

IF CONVICTED, please explain:

 

Please write a brief statement concerning why you chose to become a health care aide:

 

Text Box: Today’s Date:             Date You Want to Start Class:   Last Name:  First Name:           Mailing Address:                                                             City:  State:  Zip Code:         Race: Home Phone:                              Date of Birth: Daytime Phone:      Social Security Number: Cell Phone:                Emergency Contact:                 Relationship to You: Phone Number:   How Did You Hear About Us?   Are you over 18 years of age? Highest grade or level of school completed: School Name: Did you graduate? *GED certification date:  *Any student UNDER the age of 18 must hold a GED certificate or a high school diploma; they must also sign the enrollment agreement jointly with a parent or guardian.   Do you have any previous experience in the medical field?   If yes, please briefly explain:   HAVE YOU EVER BEEN CONVICTED OF A FELONY?   IF CONVICTED, please explain:   Please write a brief statement concerning why you chose to become a health care aide:  

Click here if you would like to download a copy of the application so that you may fax it.

 

 

Dream Maker School

                   

 

                Application