Registration Form

Payment for tuition and fees must be included with this enrollment form. Make a copy of this form for your records.
Complete this enrollment form, include payment (use any of the payment methods listed below), and mail to: Promise Healthcare Training Center 3610 Dodge Street, Suite B10 Omaha, NE 68131
A student’s Social Security number is required as a condition of enrollment. A student’s Social Security number constitutes an “educational record” under the Federal Educational Rights and Privacy Act (FERPA). That information will be disclosed only with the consent of the student or in those very limited circumstances when consent is not required by FERPA.
Social Security Number:
First name:
Middle Initial:
Last name:
Address:
City:
State:
Zipcode:
Phone Number (Day):
Phone Number (Evening):
Email address:
Birthday:
Gender:
Race (used for statistical purposes only):
Resident Status:
Course Title: Basic Nursing Assistant and Medication Aide Training 76 hours for C.N.A (completed in 2 weeks) 40 hours for C.M.A (completed in 1 week)
I am Interested In:
Registration fee, Tuition, Textbook and Testing for C.N.A = $500.00
Tuition and Textbook for C.M.A =$385.00
Registration Fee for C.M.A. (payable to Providence healthcare Institution) =$20.00
Contact Cheryl Walburn at 402-326-2792
State Exam fee for C.M.A. (payable to DHHS) =$18.00
Payment Method:
  • - select a option -
  • Check
  • Cash
  • Voucher
  • Money Order
  • Credit Cards through Paypal
Make checks and money orders payable to:
Promise Healthcare Training
Center 3610 Dodge Street, Suite B10 Omaha, NE 68131
Phone 402-968-4786
E-mail: naenyealoziem@yahoo.com
Signature:
Date: