First Name:    Last Name:

Street Address:

Apartment Number or Suite:

City:

State:

Zip Code:

Please: Provide Telephone Contact Numbers

Home Phone:

Cell Phone:

Work Phone:

Can we contact you at work?

YES   NO

What is the Best Time to Reach You by Telephone?

Morning AM          Afternoon PM

Please: Provide an E-mail Contact Address

E-mail address:

Alternative E-mail address:

What is Your Current Level of Education?

Currently attending High School

Name of your High School

Not currently in High School or didn't complete HS No problem PCI Offers Free GED Classes
(Click Here to Request Information About Obtaining Your GED)

High School Graduate

Year Graduated:

College Graduate

Year Graduated:

Why are you interested in the medical field?

How Soon are You Planning to Start School?

 I'm Ready to Start Now!    Next Month        Just Starting to Plan or Not Sure.

How Did You Hear About PCI Health Training Center Check all That Apply.

MySpace

Web Site

Television

News Paper

Yellow pages

Radio

Former Student

Mail

Dart Bus

High School Presentation

High School College/Career Fair

Other Presentation: GED class, job fair, etc. (HS)

Online Radio

Greensheet

Employment Guide

What Programs Are You Interested In?

Medical Assistant Training

Medical Office Assistant Training

Psychiatric Assistant Training (Available at The Dallas Campus Only)

Patient Care Technician

Please Send Information on All of PCI's Training Programs

Have you Enrolled or Applied for Admission at PCI before?NoYes

Please Enter Any Additional Comments or Questions Here