University of Texas at Arlington



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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______________________________________________ |

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