New Medical Assistant & Dental Assistant - Student Registration Form

10000 W. 75th Street, Suite 241
Merriam, Kansas 66204
Tel/Text: 913-708-8323
www.MACOHS.edu

Medical Assistant & Dental Assistant - Student Registration Form

STUDENT INFORMATION

Confidential

First name

Middle Name

Last name

Former Name (if applicable)

Street

City

State

Zip Code

Social Security No

Cell Phone

Do you require special accommodation for any existing health conditions, disabilities, allergies, etc.?

If yes, please specify

How did you hear about us?

PROGRAM OF INTEREST

Please select the program you are interested in:

Program

Please select your preferred course schedule option corresponding with the program you selected above.

Course Schedules - Module

EMERGENCY CONTACT INFORMATION

Contact Name

Relationship

Cell Phone

DEMOGRAPHIC INFORMATION

Birth Date

Gender

Gender (Other)

Ethnicity

Citizenship Information

Is English your first language?

Military Service Status

CURRENT EDUCATION

If you are currently attending High School, and would like to attend one of our classes, please text or call our admissions office at 913-708-8323

Are you currently attending High School?

PREVIOUS EDUCATION

Graduated from High School?

Where did you graduate High School?

If you graduated from High School, please enter the Graduation date

HS Graduation Date

Received G.E.D?

Date GED was received

Graduated from College?

Type of Degree

Are you a returning student?

Indicate program or course completed

Sponsor Information

If you are sponsored by a third-party organization, please provide their details below. For information about how to obtain sponsorship, please visit: Financial Assistance

Are you a sponsored student?

Yes No Not Selected

If yes, Name of Sponsor

Sponsor Email

Sponsor Phone contact

Payment Information

This section is for non-sponsored students. Skip this section if you are sponsored. If you intend to pay for your tuition & fees out of pocket, please complete the fields below:

Payment Method

Payment Plan

There is an additional $50.00 setup fee for all payment plans.

Student Signature

Date

Student Declaration:

After clicking "Next" below, you will be prompted to choose your program/course start date on the next screen. Submitting this form does NOT finalize your enrollment. Instructions on how to complete your enrollment will be emailed to you after you select a start date and click "Submit" on the next screen.

I certify that the information I've provided is true and accurate to the best of my knowledge.

Enter the above code

Required