Enrollment Form

This is an Enrollment Form for Northeast Medical Institute. Please read through the School Catalog and Enrollment Agreement at the end of this registration process before finishing this enrollment form.

If you are receiving State Assistance from the following orginzations (below) and are not approved yet please do not fill out this form please fill out a Financial Assistance form on our website.

WIOA( American Job Center)- Stamford
HealthCareer Academy- Bridgeport
Healthcareer Advancement Program New Haven
Workforce Alliance WIOA- New Haven
Youthworks- Bridgeport

If you are approved by one of these organizations at the end of the form please do not click on any payment options. Just leave it blank.

Personal Details

Example: 10-30-1980

This is the date you fill out this paperwork

Address

Emergency Contact

Program of Interest

Only Check if you are in the CNA or PCT Program

Only Check if you are in the Phlebotomy or PCT Program

Only Required for State Funded Students

Pick which organization you are working with

Please provide your career advisors name, email, and telephone number.

Optional Fees
CNA Registration Fee Only 256.75
CNA Program Total 1592.02
Phlebotomy Program Total 1730.49
Phlebotomy Registration Fee Only 256.75
PCT Registration Fee Only 715.50
PCT Program Total 3707.00
Total 0.00
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