Admissions Application
About You
First Name:
*
Last Name:
*
Date of Birth:
*
Cohort:
*
Select Cohort:
Cohort 3 Full-Time
Cohort 4 Part-Time
Cohort 4 Full-Time
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Contact Information
Email:
*
Phone:
*
Address:
*
Address Line 2:
*
State:
*
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Louisiana
Maine
Maryland
Massachusetts
Michigan
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Montana
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
*
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Documentation
American Heart Association Basic Life Support
*
If you have already completed Basic Life Support Training, please provide the eCard code. Basic Life Support must be completed by the beginning of Module 140.
To learn more or to find a class, visit the following link:
BLS Course Options
Government Issued Photo ID:
*
Government issued photo ID is required by the first day of class.
Transcripts:
*
Please upload copies of your high school transcripts OR records of your high school diploma/equivalent. This documentation is required by the first day of class.
Acknowledgment:
*
I agree that I have read and understand the following statement
By checking the box above, I understand that:
- The completion of AHA Basic Life Support (BLS) course and submission of the eCard code is due by the beginning of Module 140.
- A government issued photo ID is required by the first day of class.
- Transcripts or records of your high school diploma/equivalent are required before the first day of class.
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Work History (Optional)
Employer #1:
*
Employer Phone:
*
Employer Address:
*
Work Schedule:
*
Select
Full-time
Part-time
Per Diem
Agency Temp
Intern
Temporary
Contractor
Independent Contractor
Freelance
Seasonal
Start Date:
*
End Date:
*
Job Title:
*
Job Description:
*
Employer #2:
*
Employer Phone:
*
Employer Address:
*
Work Schedule:
*
Select
Full-time
Part-time
Per Diem
Agency Temp
Intern
Temporary
Contractor
Independent Contractor
Freelance
Seasonal
Start Date:
*
End Date:
*
Job Title:
*
Job Description:
*
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Submit Application
How did you hear about us?
*
Select
Online search or advertisement
Social media
Brochure or other printed material
Referral by friend or family member
Referral from other organization
Open house
FHCSD employee
Job or college fair
Other
If other, please describe below:
*
Are you a current patient at Family Health Centers of San Diego (FHCSD)?
*
Select
Yes I am a FHCSD patient
No I am not a FHCSD patient
If you are a FHCSD patient, write the location you visit below:
*
Fees
Mandatory Fees
Application Fee
100
Total
100.00
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