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HALIFAX ACADEMY FOR CAREGIVERS, INC. APPLICATION DATE:                                           NAME:               DATE OF BIRTH: STREET ADDRESS: CITY:        STATE:        ZIP CODE: HOME PHONE:        WORK:        CELL:        E-MAIL ADDRESS: ARE YOU LEGALLY ELIGIBLE TO WORK IN THE U.S.?        YES        NO ARE YOU ABLE TO READ AND WRITE IN ENGLISH?        YES        NO ARE YOU AT LEAST 18 YEARS OLD?:        YES        NO (IF ?NO?, PARENTAL PERMISSION AND HIGH SCHOOL DIPLOMA OR GED REQUIRED) HAVE YOU EVER BEEN CONVICTED OF A FELONY?:        YES        NO IF YES PLEASE STATE THE NATURE OF THE FELONY AND THE DATE OF THE OFFENSE: DEPOSIT POLICY: I UNDERSTAND THAT THE SEAT DEPOSIT OF $150.00 IS NON-REFUNDABLE***.        YES        NO *** The $150 will be forfeited (you will give up your $150 deposit) for cancelations or if you dont show up for class. (The $150 is applied to the $450 total, so your balance due is $300) HALIFAX ACADEMY FOR CAREGIVERS, INC. IS COMMITTED TO GIVING YOU EVERY POSSIBLE CHANCE TO PASS THE STATE CERTIFICATION EXAM. IF FOR ANY REASON YOU DO NOT PASS THE TEST, YOU MAY SIT IN ON ONE ADDITIONAL WEEK LONG COURSE AT NO ADDITIONAL COST TO YOU. DATE YOU WISH TO ATTEND: BY TYPING YOUR NAME BELOW YOU HEREBY AGREE THAT THIS IS EQUIVALENT TO YOUR LEGAL SIGNATURE. SIGNATURE:                      DATE:

Halifax Academy for Care Givers, Inc. · 2900 S. Nova Road Suite 3 · South Daytona · 32119

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