Hearts Associates Institute
1054 Gateway Blvd - Suite 110, Boynton Beach, FL 33426
HAI ONLINE APPLICATION
First Name
Middle Name
Last Name
Street
City
State/Province
...
Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
Armed Forces
Armed Forces Americas
Armed Forces Pacific
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland
North Carolina
North Dakota
Northern Mariana Islands
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Palau
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
N/A
Zip/Postcode
Are you at least 18 years of age?
Yes
No
Not Selected
Name of Parent/Guardian (if student is under 18)
Cell Phone
Home Phone
Spouse
Spouse Phone
Email
Birth Date
Date of Birth
EMERGENCY CONTACT
Contact Name
Relationship
Contact Address
Contact City
Contact State
Contact Zip Code
Contact County
Cell Phone
Email
By providing email address, cell phone & cell phone carrier information, I am authorizing the school to contact me via these methods. (Student Initials)
I am authorizing the school to contact me via these methods. (Student Initials here)
Race
Alaskan Native
American Indian
Asian
African American
Hispanic
Caucasian
Marital Status:
Single
Married
Divorced
Widowed
Education Level
HS Diploma
GED
College Grad
Current HS Student
Some Post Secondary
Associates Degree
Gender (M/F)
Female
Male
High School Graduate?
Yes
No
Not Selected
If still in high school, what grade level are you currently in?
How Did You Hear About Us?
Driver’s License/State ID
State License Issued
Veteran
Yes
No
Program
...
EKG Technician (EKG)
HOME HEALTH AIDE (HHA)
MEDICAL ASSISTANT (MA)
NURSING ASSISTANT (NA)
PATIENT CARE TECHNICIAN (PCT)
Phlebotomy Technician (PT)
REFERENCES
Parent/Guardian
Name
Address
City
State
Phone
Zip
Cell Phone
Reference 1
Name
Address
City
State
Phone
Zip
Cell Phone
Reference 2
Name
Address
R2 City
State
Phone
R2 Zip
Cell Phone
Applicant's signature
Student Printed Name
Guardian’s Signature (If Applicant is Under 18)
Date applicant signed
Enter the above code
Required