Application Form

Thank you for your expressed interest in this course. Feel free to fill out the enrollment form below and someone will get back with you as soon as possible with further details.

Are you a citizen of the United States? *
Have you ever applied to Visionary Health Career Training Institute? *
If no, are you authorized to work in the U.S? *
Have you ever been a Certified Nursing Assistant? *
Have you ever been convicted of a felony? *


Did you graduate high school?


Did you graduate college?


Did you graduate Other Education?



**You do not have to list three jobs if you had fewer**

Military Service

Disclaimer and Signature

If this application leads to acceptance to Visionary Health Career Training Institute. I understand that false or misleading information in my application may result in dismissal from the program.

Consent To Perform Criminal History Background Check

This authorization and consent for release of personal information acknowledges that Visionary Health Career Training Institute (Hereafter referred to as "Company") and/or its agent, may now, or at any time I am assigned to, volunteer with or attending classes or am employed by this Company, conduct investigations whether the records are of a public, private or confidential nature. These investigations might include, but are not limited to, searches of educational institutions attended; financial or credit institutions, including records of loans; records of commercial or retail credit agencies; other financial statements; records of previous employment, including work history, efficiency ratings, complaints and grievances filed by or against me; records and recollections of attorney-at-law or of other counsel, whether representing me or any other person (in either a civil or criminal case in which I have been involved); records from the U.S. Veterans' Administration; criminal history information of file in local, state or federal agencies; and motor vehicle records, and following an employment offer, workers' compensation reports from either the Department of Labor, National Personnel Records or the Industrial Commission or similar agencies under the provisions of the Fair Credit Reporting Act 15, USC section 1681 et seq.

I understand that these searches will be used to determine school assignment or employment eligibility under the company's school admission, employment or volunteer policies. Therefore, I authorize and consent for full release of records (either orally or in writing) to the authorized representatives of the company. In addition, I release and discharge the company and its agent and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs expenses or any other charge or complaint filed with any agency arising from retrieving and reporting this information. I understand that per the Federal Fair Credit Reporting Act, I am entitled to know whether enrollment was denied based upon the information obtained and to receive, upon written request, a disclosure of the background report. I also understand that I may request a copy of the report by contacting Visionary Health Career Training Institute.

The following are my responses to questions about my criminal record history (if any) with descriptions to any question with a YES answer:

Have you ever been convicted or plead guilty before a court of any federal, state, or municipal criminal offense? (Excluding minor traffic violations) If YES please provide an explanation below:
Have you ever receive deferred adjudication or similar disposition for any federal, state or municipal criminal offense?
Have you ever received probation or supervision for any federal, state or municipal criminal offense?
Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States?
As of the date of this authorization, do you have any pending criminal charges against you?