American Academy of Healthcare, LLC

Enrollment Application

4917 Albemarle Road, Suite 207, Charlotte, NC 28205 · 704-525-3500

Personal Information

Tell us who you are. This becomes your enrollment agreement record.

Full Name*

Date of Birth*

Social Security #

Email Address*

Address*

City*

State*

Zip*

Home Phone

Cell Phone*

Alternate Contact #

Emergency Contact #*

Program Information

Select the program you are applying to.

Preferred Start Date

Preferred End Date

Class Schedule (day of week)

Education History

High School / GED

School Name & Address

Degree / Diploma

Start (MM/YYYY)

End / Graduation (MM/YYYY)

College / University

School

Degree

Start (MM/YYYY)

End (MM/YYYY)

Other Education / Certifications

Employment History

Most recent employer first.

Employer 1 Name & Address

Position

Start

End

Employer 2 Name & Address

Position

Start

End

Student Interview

Please answer briefly — used in your admissions interview.

What do you think it takes to be a good Nurse Aide / healthcare worker?

What are 3 words your friends would use to describe you?

Describe a time when you had to learn something new. How did you learn it?

Describe your best learning experience. What made it good?

Where do you see yourself in 3–5 years?

Emergency Notification

Emergency Contact Name*

Relationship

Phone Number*

Hospital Preference

Allergies

Fees & Charges

Total: $955.00 — requirements will be deducted.

Item	Amount	Notes
Registration Fee	$50.00	Non-refundable
Tuition	$750.00
Text Book	N/A
Background Check	$30.00	Mandatory, done on premises
Uniform	$25.00	Mandatory, school stock
Drug Screen	$45.00	Within last year
CPR (American Heart)	$55.00	Within 2 years
Total	$955.00	Cash or money order — no checks

Acknowledgements

Please review and check each item to confirm you understand and agree.

I have reviewed and agree to the Attendance and Uniform Policy.I have reviewed the Privacy Acknowledgement and Non-Disclosure Agreement.I understand the Competency Evaluation Skills Testing Procedures.I understand all student fees must be paid in full prior to clinical rotation.I understand a Hepatitis B / Flu declination form may be required, and that I must provide an Immunization Record, TB results, Physical Examination, and pass a Criminal Background Check before clinical rotation.I understand the Refund Policy, the school's Right to Cancel, and that the $50 registration fee is non-refundable.I have received (or will receive) the Student Handbook & Enrollment Agreement and agree to follow all rules and expectations.

Type Your Full Name (Signature)*

Date*

By typing your name above, you electronically sign this enrollment agreement and certify the information you provided is true and accurate.

Bring originals on your first day: ID, SS card, immunization record, physical exam, and the $50 registration fee.