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Enrollment application

Take the next step toward your healthcare career. Complete this application and our admissions team will contact you with availability and next steps.

Five short steps
About 10 minutes
English, Haitian Creole, Spanish

Required field. Please do not enter Social Security, banking or credit-card information on this form.

Program and schedule

Which program you want, and when and how you would like to study.

Program of interest

Program availability, admission requirements and start dates are confirmed by our admissions team.

When would you like to start?

Preferred schedule

Preferred language

Payment preference

About you

Your name as it appears on your government-issued ID, and how to reach you.

Legal first name

Legal last name

Preferred name

Date of birth

Email address

Mobile phone

Best way to contact you

Address and emergency contact

Where you live, and who we should call in an emergency while you are training with us.

Street address

City

State

ZIP code

Emergency contact

Full name

Relationship to you

Phone number

Education and background

Where you are starting from, and how you heard about us.

Highest level of education completed

Current healthcare role

Do you currently hold a healthcare license or certification?

YesNo

What would you like this program to help you accomplish?

How did you hear about Jude Health Institute?

Who referred you, if anyone?

Review and sign

Check your answers, then read and accept the statements below.

Submitting this form is an application. It does not guarantee acceptance, reserve a seat or complete enrollment. Our admissions team will confirm program requirements, tuition, payment arrangements and the official start date before enrollment is finalized.

I certify that the information I have provided is true and complete to the best of my knowledge. I understand that I must review and sign the applicable enrollment agreement, cancellation and refund policy, attendance policy and student policies before my enrollment is complete. I authorize Jude Health Institute to contact me by phone or email about this application. Optional: I agree to receive admissions-related text messages. Message and data rates may apply. Message frequency varies. Reply STOP to opt out or HELP for help. Consent is not a condition of purchase.

Electronic signature: type your full legal name

Date

Your application is sent over a secure connection and used for admissions and enrollment, as described in our Privacy Policy. By applying you agree to our Terms.

Enrollment application

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