New CMA Update & CNA Refresher - Student Registration Form

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

CMA Update & CNA Refresher - Student Registration Form

STUDENT INFORMATION

Confidential

First name

Middle Name

Last name

Former Name (if applicable)

Street

City

State

Zip Code

Country

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

For the program you selected above, you will select a start date and schedule option on the next page.

KDADS CNA or CMA License Information

If you do not know your license information, click here to look yourself up in the Kansas Nurse Aide Registry

Kansas CNA Aide ID #:

MUST BE KANSAS CNA

License Inactive Date

DEMOGRAPHIC INFORMATION

Birth Date

Gender

Gender (Other)

Ethnicity

Citizenship Information

Is English your first language?

Military Service Status

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 select your payment method below:

Payment Method

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