Bethel House Training Institute - Committed to Training Students for EXCELLENCE in Caregiving.

Enrollment Application
Name:
Address:
Phone Number:
Date of Birth:
Social Security Number:
Email:
Have you ever been a CNA or CMA before?
Yes
No
Choose the course you would like to Enroll in:
What class date would you like to enroll in?
Have you ever been convicted of a Felony?
No
Yes
If you answered yes above, please explain
Please list someone we can contact in case of an Emergency: (include Name and phone number)
Payment Options
Pay in Full
Payment Arrangement
Financial Aide (workforce, SRS, Goals)
Today's Date