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Student Registration Form

First Name (Legal)*

Last Name (Legal)*

Date of Birth (MM/DD/YYYY)*

Email Address*

Phone Number*

Mailing Address (Street, City, State, ZIP)*

Course / Program Selection*

Skills-Training Availability — select all times you can attend*

Weekday Morning — 9:00 a.m.–2:00 p.m.

Weekday Evening — 6:00 p.m.–10:00 p.m.

Weekend

Flexible — I can attend any available session

Not applicable — online-only program

Preferred Schedule and Learning Format — select all that apply

Online / virtual learning

In-person training

Hybrid / blended learning

As soon as possible

Healthcare Background — select all that apply

I am new to healthcare

I currently work as a caregiver / HHA / CNA / PCT

I need job placement assistance

I have a resume

I am interested in travel caregiving opportunities

I am renewing or updating a current healthcare credential

Specific Preferred Start Date (optional)

Month

Day

Year

Upload a clear copy of your photo ID*

I confirm that the information provided in this application is true and accurate.*

I understand that submitting this form does not guarantee enrollment until DCA Academy confirms my eligibility, course availability, payment, and required documents.*

I authorize Dynamic Career Advancement Academy to contact me by phone, text, or email regarding my enrollment, course options, documents, and job placement opportunities.*

I understand that I may be asked to provide additional documents before enrollment is finalized.*

Digital Signature — Type your full legal name to sign*

Date Signed (MM/DD/YYYY)*