Division for Enterprise Development 140 W. Mitchell St. Arlington, Texas 76019 817-272-2581

Health Careers Institute

Division for Enterprise Development 140 W. Mitchell St. Arlington, Texas 76019 817-272-2581

Healthcare Program Application

Last Name / First Name / Middle Initial
Mailing Address / City / State / Zip Code
Home Phone / Cell Phone
Email Address
Social Security No. / Date of Birth / Gender
Male

Female
Citizenship
(Please mark one)

U.S. Citizen Yes No If no, Citizenship of ______
Permanent Resident Yes No
Previous Education

Do you have a High School Diploma/GED? Yes No If no, the highest grade completed ______
Additional Education:______
Healthcare Training:______
Training Program Interest

Certified Nurse Aide EKG Technician Phlebotomy Technician

Patient Care Technician Dental Assistant Pharmacy Technician

Medical Administrative Asst. Medical Coding & Billing Veterinary Assistant
Other ______
Health Questionnaire

Do you have any physical limitations which would affect your ability Yes No
to lift, turn, or transfer patients?

Do you have any limitations in use of your senses, such as in sight or Yes No
hearing, which would limit your ability to practice a health profession?

Do you have any other condition which might interfere with your ability Yes No
to practice a health profession?
If you have answered “Yes” to any of the above questions, please explain your limitations in detail in the space provided below.
Additional Information

Do you have health insurance? Yes No
How did you hear about UT Arlington’s Continuing Education?

Friend Employment News Green Sheet Continuing Education Catalog

UTA Website Other ______
Emergency Contact
Last Name / First Name / Middle Initial
Mailing Address / City / State / Zip Code
Contact Phone Number / Relationship
APPLICANT STATEMENT AND SIGNATURE
I understand that I am responsible for the information provided in this application. I have submitted information that is completely true and correct. I understand that any information that is not true may cause me not to be accepted in the training program or to be dismissed from the program. I understand that upon acceptance of enrollment into the healthcare program of my choice, a criminal background check, immunization record, and drug screen may be required. I also understand that if I am not accepted for training or if I decide not to attend, my application will be destroyed.
Applicant Signature______Date______
For Office Use Only
Admissions Advisor’s Signature______Date______

Applicant Accepted? Yes No If no, Reason for Denial______
______

Bidsheet Submitted? Yes No Agency______
Date______