Application fee is $49. Forms may be submitted without payment. If applying for a CNA scholarship no app payment is required unless otherwise instructed. First Name *Middle Inital *Last Name *Email Address *Phone Number *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Which class are you enrolling? *CNA CadillacCNA FrankfortCNA GaylordCNA Harbor SpringsCNA Reed CityCNA Traverse CityEMT CadillacEMT Traverse CityMFR CadillacMFR Traverse CityPharmacy Tech National Exam PrepClass Start Date *Payment Method *Please select an optionIn Full PaymentMI WorksPayPlanScholarshipOtherWho is you representative at MI Works? *Who is sponsoring your scholarship? *Please select an optionAccelerate The CureAltercare (Big Rapids)Autumnwood (McBain)Bay Bluffs (Harbor Springs)Boulder Park (Charlevoix)Grand Oaks (Baldwin)Grandvue Medical Facility (East Jordan)Helen Newberry Joy (Newberry)Kings Nursing & Rehabilitation (Houghton Lake)Manistee Medical Care FacilityMaples Benzie Care Facility (Frankfort)Medilodge of GaylordMedilodge of Grand Traverse CountyMedilodge of LeelanauMedilodge of LudingtonMedilodge of Traverse CityMetron of Big RapidsOakview Medical Care Facility (Ludington)Orchard Creek (Traverse City)PACE North (Traverse City)Paul Oliver Memorial Hospital (Frankfort)Samaritas (Cadillac)Spectrum Hospital (Reed City)Villa at The Bay (Petoskey)Villa at Traverse Point (Traverse City)Choose oneDescribe your Other payment method: *Other/Maiden Names (used only for required background check) *Birthdate (used only for required background check) *Gender (used only for required background check) *Please select an optionFemaleMaleRace (used only for required background check) *Please select an optionAmerican Indian/Alaskan NativeAsian/Pacific IslanderBlackWhiteOtherScrub/Uniform Top Size (CNA course only)XXSXSSMLXL2XL3XLEmergency Contact Name *Emergency Contact Phone *How did you hear about Agape? *Please select an optionEmployerFacebookFlyerFriendRadioWeb SearchConsent *Yes, I agree with the Refund Policy, Media Policy, and Validation Policy.Additional Message SubmitPlease do not fill in this field. If you have any questions or issues please CONTACT US
