• First Name *
• Last Name *
• Address *
• City *
• State * Array-- Choose A State -- Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia 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 Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Puerto Rico Québec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
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• Email (Optional)
• Phone * () -
• Other Phone (Optional) () -

• Did you attend high school? * Yes No
• What is the highest level completed? * -Chose One- Nine Ten Eleven Twelve
• Did you attend any previous colleges? * Yes No
• Did you finish? * Yes No

More about you

• How did you hear about us? -Choose One- Radio Google Search Yahoo Search Penny Saver Yellow Pages Student Referral Friend
• Please Choose Campus? -Choose One- Lancaster, CA Ventura, CA
• What program(s) are you interested in? -Choose one- Vocational Nursing (Offered at both campuses) Massage Therapy (Offered in Lancaster) Medical Assisting (Offered at both campuses) Medical Billing (Offered in Lancaster) Dental Assisting (Offered at both campuses) Limited X-Ray Technician (Offered at both campuses)

• Why have you selected this program(s)?

Schedule Date & Time

• Month: 1 2 3 4 5 6 7 8 9 10 11 12 / Day: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2009
• Time: 9:00am 9:30am 10:00am 10:30am 11:00am 11:30am 12:00pm 12:30pm 1:00pm 1:30pm 2:00pm 2:30pm 3:00pm 3:30pm 4:00pm 4:30pm 5:00pm 5:30pm 6:00pm
• Please Note: Appointments will be confirmed by the admissions department. If appointments cannot be accommodated at time and date specified, a representative will contact you shortly with the next available appointment.