LC - Online Course Application Form

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LC - Online Course Application Form

Please complete all sections of this application form.

Write your Full Name in the space provided below. *

First and last name

Email: *

Phone number: *

Date of Birth: *

YYYY

Current home mailing address: *

Answer the following: *

Male

Female

Required

Academic Information

High School Name if applicable.

Date of High school Graduation:

YYYY

Program of Choice: *

Nursing skills and Patient Care [12 weeks]

Geriatric Patient care [12 weeks]

Dementia care and Management [6 weeks]

Fundamentals of Phlebotomy [6 weeks]

Behavioral science [12 weeks]

Neuropsychology [12 weeks]

Psychology [12 weeks]

Managing Health and Safety in Healthcare [6 weeks]

Pharmacy Assistant [12 weeks]

Foundation of Medical Sciences [Associate Degree] [2 years]

Medical and Clinical Administration [12 weeks]

Customer Service skills within Healthcare [12 weeks]

Foundation of Healthcare Management [12 weeks]

Anatomy and Physiology [16 weeks]

Required

Emergency contact: *

Phone number.

Emergency contact: *

Name of Next of Kin.

Emergency contact: *

Relationship to kin.

Mother

Father

Sibling

Spouse

Guardian

Others

Required

Are you currently employed? *

Yes

Required

Have you ever been placed on probation, suspended, removed, dismissed or expelled from any school or academic program since the 9th grade? *

Yes

Required

Have you ever been convicted of any misdemeanor, felony, or other crime? *

Yes

Required

Authorization: I confirm all information in this application (including any supplemental information) is factually true and honestly presented and that you are the person submitting this application. *

Write your Full Name in the space provided below.

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