Application for CHHA Class Admission – Allied Health Training Institute

Consider each question carefully. Answer each question truthfully and submit the form below. Once the form is submitted successfully you will see a Pay Now button in the confirmation field. You must submit a non-refundable deposit of $237.50. This deposit will go towards total tuition at completion of class.

2/17/23: Open for new admissions
6/9/23: Open for new admissions

NOTE: Allied Health Training Institute is an Equal Opportunity Association which does not select students on the basis of their sex, marital status, ethnic origin or religious preference. The following information is for reporting and identification purpose only and does not affect admission.

Are you Registering for our CHHA Class? *

Note: If you are looking for a different class then our CHHA class, please select that from the main navigation and fill out that form instead.

Course Date *

First Name *

Last Name *

SS#

DOB *

Month/Day/Year

Email *

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Gender *

Residency *

Ethnicity *

Emergency Contact

Name *

First

Last

Phone *

Relationship to Contact *

Do you have any responsibilities that may interfere with this program? *

If yes, specify:

Where did you hear about the school?

Internet
Friend
Other

Have you ever been convicted of a criminal act? *

If yes, specify:

Signature: With this signature I have authorized AHTI to perform a criminal background check. I certify that, to the best of my knowledge and belief, all of my statements are true, correct and complete. I understand that any false or incomplete statements are grounds for denial of admission or dismissal from Allied Health Training Institute without a complete or partial refund.

Signature: *

Date: *