Application for Student Admissions Student First Name * First Name Student Last Name * Last Name Gender * Male Female Age * Date of Birth * Social Security Number * Address * City State ALAKASAZCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code * Phone * Other Phone Your Email Address * Race Hispanic/Latino (of any race) Native Hawaiian/Pacific Islander American Indian/Alaskan Native Black/African American White Asian Race/Ethnicity Unknown Wish Not to Disclose Citizenship - Legal Status US Citizen Permanent Resident Student Visa Parolee Work Permit Other Did you graduate from High School? Yes No GED Did you graduate High School in the past 12 months? Yes No Is this the first time you attend a school at an undergraduate or postsecondary level school? Yes No ADMISSION POLICY: Applicants with a high school diploma or GED are eligible to enroll in any of the programs offered by Life-Line Med Training. By signing this application you agree that all materials submitted by you for purposes of admission become the property of Life-Line Med Training. REGISTRATION FEE: There is a $50 non-refundable registration that must be paid with the submission of this Application payable to “Life-Line Med Training”. The registration fee may be refunded if requested by the Applicant in writing to the School Director within (5) business days prior to class start date. If Applicant is not accepted by Life-Line Med Training, for any reason, all monies paid will be refunded, including, but not limited to, the application fee. NON-DISCRIMINATION POLICY: No person shall be excluded from participation in Life-Line Med Training or be subject to any form of discrimination because of race, color, sex, national origin, religion, age, marital status, sexual orientation, veteran status, or disability. I hereby certify that all information provided by me in this application is true and correct to the best of my knowledge. By entering my First and Last Name BELOW, as it appears on my State Issued ID I agree to the terms of registration. Student Name (As it appears on your State Issued Identification) * First and Last Name Today's Date Program of Interest Clinical Medical AssistantEKG TechnicianHome Health AideNursing AssistantMedical Coding & Billing SpecialistPatient Care TechnicianPhlebotomy TechnicianCPR Instructor Registration Fee $50 After submitting this form, you will be redirected to PayPal for the processing of your $50 application fee. Captcha Submit Δ