REGISTRATION FORM Online Apply online by filling out the form below Mail Download and complete the registration form and mail it to the training center. Registration REGISTRATION FORM Promise Healthcare Training Center 3610 Dodge Street, Suite B10 Omaha, NE 68131 402-968-4786 Payment for tuition and fees must be included with this enrollment form. Make a copy of this form for your records. 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 * Email * First Name * Middle Name Last Name * Address * City * State * Zip * Phone (Day) * Phone (Evening) Birth Date * Gender * Male Female Resident Status * Resident of Nebraska Non-resident of Nebraska Race (used for statistical purposes only) Asian/Pacific Island Hispanic/Latino White/Non-Hispanic Black/African American Native American Other Course Title: Basic Nursing Assistant and Medication Aide Training84 hours for C.N.A (completed in 2 weeks)40 hours for C.M.A (completed in 1 week) I am interested in * C.N.A C.M.A Both Registration fee, Tuition, Textbook and Testing for C.N.A = $600.00 Registration fee, Tuition and Textbook for C.M.A = $385.00 Exam 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 Choose your payment method Cash Check Credit Card Money Order Voucher 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 Student's Electronic Signature (Type your full name) * Date * Instructor's Signature Date reCAPTCHA Text Payment Website/URL Name Name First First Last Last Dropdown Option 1 Checkboxes Option 1 Option 2 Paragraph Dropdown Option 1 Dropdown Option 1 Email Radio Buttons Option 1 Option 2 Paragraph Number Text Submit
