Med Aide First Page

							Teamwork Services

                                                                                            307 East Pioneer Pkwy
                                                                                           Grand Prairie, TX 75051
                                                                                                 Tel 972-263-7941
                                                                                                Fax 972-237-7854
                                  MEDICATION AIDE PROGRAM
                                       STUDENT ENROLLMENT AGREEMENT

Please attach the following documents:

        Copy of High School Diploma or GED or College Transcript (please if foreign, have this evaluated).
        Copy of Driver’s License
        Copy of CNA License
        Copy of Social Security Card (SSN) or Tax Identification Number (TaxID)

    1.    Name:                 _________________________              ________________           ______________
                                           Last                             Middle                     First

    2.    Home Address:         _________________________             ___________       ____________    __________
                                          Street                          City              State           Zip

    3.    Social Security:      _________________________              4.      Date of Birth   ____________________

    5.    Home No:              _________________________            Cell:     ___________     Work:   ____________

    6.    Email Address:        _________________________

    7.    Date Class begins:    ____________      Date class ends:          _________      Program Length     _______

    8.    Current Employment in a Long Term Facility:

          Name of Facility:     ___________________________________________________________________

          Address:              ___________________________________________________________________

          ____________________________________________________________________________________

    9.    Payment:

          Registration          $100.00
          Tuition               $425.00
          State Exam            $ 25.00
          Total Cost            $550.00

          “Any holder of this consumer credit contract is subject to all claims and defenses which the debtor could
          assert against the seller of goods or services obtained pursuant hereto or with the proceeds hereof.
          Recovery hereunder by the debtor shall not exceed the amounts paid by the debtor hereunder.”

    Teamwork Services will give equal opportunity to all applicants regardless of race, sex or natural origin. This
    is approved and regulated by the Texas Workforce Commission, Proprietary School section in Austin, Texas.

    Date: ________________________________                        Signature of Tour: _______________________

    Student Signature: _____________________           Date: ______________          Print Name: _____________

    School Official Signature: ________________        Date: ______________          Print Name: _____________


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