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First Name *

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M.I.

Last Name *

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Address *

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Apt #

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City *

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State *

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Zip Code *

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Phone *

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Emergency Contact Name *

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Emergency Phone Number *

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Which classes are you enrolling? *

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Which date(s) are you interested in? (Calendar) *

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Email:

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How did you hear about us? *

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Other *

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Title *

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For Sponsoring Agency Only: To comply with State Regulations, the following information must be completed.

Facility

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Contact Person

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Contact Number

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I affirm that the information I have provided on this application, including responses to any other information that I have submitted or will submit to Premier Choice Health Services in connection with the admission, is complete and accurate and is my own work. I understand that submission of incomplete or inaccurate information is sufficient cause for revocation of admission or enrollment.

I agree to the statement above
Please agree to the terms and conditions
I have read the student policy agreement
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Electronic Initials *

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Date *

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REGISTER ONLINE

We make it simpleto succeed!

We make it simple
to succeed!