HPA Interest Form

Health Professions Academy Program Interest Form

Date*
Date Format: MM slash DD slash YYYY
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM
DD
YYYY
Email*
Phone*
What classes do you plan to attend? Check all that apply.*
- State Tested Nursing Assistant (STNA) at Scarlet Oaks Career Campus
- Patient Care Assistant at Scarlet Oaks Career Campus
- STNA/PCA Plus at the Scarlet Oaks Campus
How will you pay for the class?*
- Out of pocket
- Will apply for funding
- Check here if you are receiving SNAP (food stamp assistance)
When do you plan to begin (if known)?
If you are already working with an agency/support organization, please list agency name, contact name & phone number:
How did you hear about the Health Professions Academy and our classes?
Have you already watched the Information Session video?*
- Yes
- No
Viewing this video is a required part of the admission process. A link to the video will be provided after you submit this form.
Consent*
I give my permission for the above information to be shared with others. This information will only be used for admission purposes at Great Oaks Career Campuses and will not be sold.