Get Enrolled Form

* = Required Information

Last Name *

First Name *

Other Names Used (e.g. maiden name)

Street Address *

County

City

State

Zip

Email Addres *

Primary Phone Number (Please check one) * Home Cell Business

Alternate Phone Number (Please check one) Home Cell Business

To comply with our reporting requirements, Allied Health Technology Institute requests your Social Security number and birth date – this information will not be used as your student ID number.

Social Security Number *

Date of Birth *

Please present your driver's license, an ID card, or a voter registration card with your application in order for us to verify your identity.

Individual to notify in case of an emergency *

Relation

Phone Number

How did you hear about us?