Registration - Michigan Healthcare Academy

School Registration *Please fill out this form and purchase a program under "buy now" of the course you wish to sign up for.

First Name *

Last Name *

Telephone # *

Email *

Password *

Address *

City *

State *

Zip Code *

DOB *

I am registering for the class starting *

Last 4 digits of your Social Security Number (for identification purposes only) *

Emergency Contact Number

Emergency Contact Name

How did you hear about us? *

Referral
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Other

I was referred by: (name & address) We would like to show our appreciation to the friend or family member who referred you. Please enter their legal name and correct address in the box below. Current promotion: $50 referral appreciation check issued when the registered student successfully completes the Nurse Aide Training Program. Only one referral source (one person) accepted for each student who successfully completes our Nurse Aide Training Program. Only one check will be issued.

I agree with all Terms and Conditions *Terms and Conditions

School Registration *Please fill out this form and purchase a program under "buy now" of the course you wish to sign up for.

Thanks for registering with us...we love making new friends!