Enrollment Application Form

First Name *

Last Name *

Other Names Used (e.g. maiden name)

Street Address *

County

City *

State *

Zip *

Email Address *

Primary Phone Number (Please check one) *

Home

Cell

Business

Alternate Phone Number (Please check one)

Home

Cell

Business

Allied Health & Technology Institute requests your Social Security number and birth date to comply with our reporting requirements. Your Social Security number will not be used as your primary student identification number.

Social Security Number *

Date of Birth *

In order for Allied Health & Technology Institute to properly verify your address, please present your driver’s license, a State issued ID card, or a voter registration card with your application.

Individual to notify in case of an emergency *

Relation

Phone Number

How did you hear about our school?

Refund Policy

The tuition and fees paid by the applicant shall be refunded if the applicant is rejected by the school before enrollment. Allied Health & Technology Institute will notify each applicant who is rejected by the school before the enrollment date. An application & Entrance Exam fee of not more than $75 may be retained by the school if the application is denied. All tuition and fees paid by the applicant shall be refunded if requested within 3 business days after signing a contract with the school. All refunds shall be returned within 30 days. Delays may occur in processing if a student has not provided the school with a current address. Allied Health & Technology Institute does not discriminate in its educational programs, activities, admissions, or employment on the basis of race, color, sex, national origin, handicap, sexual orientation, age, political affiliation, or beliefs as required by Title VI of the Higher Education Amendments, Title IX of the Civil Rights Act, Section 504 of the Rehabilitation Act. Questions concerning Allied Health & Technology Institute non-discrimination policies may be addressed to the Office of Admissions, 202-526-3535.

Have you ever been convicted of a crime, misdemeanor, or felony?

Yes

No

If yes, please explain

Gender

Male

Female

Ethnic Background (optional)

Asian or Pacific Islander

Black, non-Hispanic

Native American or Alaskan Native

White, non-Hispanic

Citizenship Status

US Citizen

Permanent Resident or Resident Alien Hispanic (provide Alien Registration Card from 1-551)

Refugee or Asylum Status White, non-Hispanic (provide Proof of status from USCIS)

When I first attend classes at AHTI my education level will be:

Still attending high school (requires high school signature below)

High school graduate or GED

Non-high school graduate

Associate degree or less

More than 2 years, but less than a 4 year degree

Four-year college graduate

More than 4 years of college

Current/Last high school attended

State

Year you received or expect to receive your High school diploma or GED

Program Selection (Please select one)

Home Health Aide	Certified Nurse Assistant	CNA-HHA (Bridge program)	MED TECH (MD)
TME (DC)	PHLEBOTOMY

Month

Year

DOES Works Case Worker:

Phone

I certify that all answers given to questions in this application are correct and complete, and agree to abide by the regulations of AHTI.