Community-Based Residential Facility (CBRF) Training Registration Form
Thank you for choosing Core Care Healthcare Training Center, LLC. for your healthcare training needs. We are excited to have you join our class! Please complete the registration form completely and submit your form.
We will be in contact via email to complete the registration process, and to discuss payment options.

Payment accepted:
1. SQUARE PAYMENT Invoice -CREDIT OR DEBIT CARD (VISA, MASTER CARD, AMERICAN EXPRESS) ONLINE VIA PAYMENT OF EMAILED INVOICE
2. CASH PAYMENT (IN FULL)- TWO BUSINESS DAYS PRIOR TO START OF TRAINING
3. MONEY ORDER OR CASHIER'S CHECK PAYABLE TO CORECARE HEALTHCARE TRAINING CENTER, LLC. C/O TERESA GUYTON
4. ZELLE PAYMENT- PLEASE CONFIRM THIS OPTION FIRST
************NO CHECKS**************

Please Note: Classes are are offered Monday-Friday (A.M.) Weekends classes are offered twice monthly. If you are are interested in group staff training, or have questions regarding class schedules please contact us via phone or email.

Thank you.

Core Care Healthcare Training Center, LLC.
6830 W. Villard Ave.
Milwaukee, WI.
Phone: 414-458-1661  
Email: corecarecbrftraining@gmail.com 
Website: www.corecarecbrftraining.com 
Sign in to Google to save your progress. Learn more
Email *
Today's Date *
MM
/
DD
/
YYYY
Student Name (First, Middle Initial, Last) -Please list full name and check spelling for state registry purposes. *
Date of Birth *
MM
/
DD
/
YYYY
Address, City, State, Zip *
Phone Number *
Basic Skills Screening Tool (Check All That Apply) *
Required
Name of Employer (If your training is through your employer, please list Name, Address, Phone Number, and Email Address if available) List N/A if No. *
What date are you interested in starting training? *
MM
/
DD
/
YYYY
How would you like to complete your training? Please note: Medication Administration is a two part training. This course can be completed hybrid (virtual and Part 2 in person). If opting for virtual medication training, participants MUST have a valid verifiable testing  proctor available for skills demonstration portion before testing virtually. *
CBRF Training (Weekday Mornings/ Weekend Saturday/Sunday start times may vary) Please contact for group rates for staff training. *
Required
Additional Training & Workshops (Weekends Only Saturday/Sunday) Please contact for Weekday Training *
Required
Registration for classes require FULL payment to hold a seat for training.  CCHTC is a service based business, therefor instructors are compensated for class prep time and materials. SPECIAL NOTE: CLASSES HAVE BEEN ADJUSTED DUE TO THE MOST RECENT COVID-19 PANDEMIC. YOUR SAFETY IS OUR PRIORTY. 1.Students must bring and wear a mask at all times during class.  2.Gloves, sanitizer, and PPE equipment will be available for skills portion of training. 3. Social distancing will be maintained at all times. 4.If you feel ill or present symptoms of COVID-19 (fever, sore throat, coughing, vomiting, body aches, chest pain or SOB) before class DO NOT COME TO CLASS.  5. Students may be asked to leave if signs of illness are present on day of training. 6. Classes of 6 students or less will be held at Core Care Healthcare Training Center's location. If your facility permits space for more than 6 students or staff to be trained while adhering to CDC's social distancing recommendations, no more than 10 students will be trained at once. Please agree with terms below: *
Required
eSignature Agreement- By purchasing a service and reviewing the above terms, I agree to all statements and terms. I acknowledge by typing my name electronically, I have read and agreed to the polices and terms listed above and I am bound to the outlined contract with Core Care Healthcare Training Center, LLC. Core Care has the right to amend and or terminate services/ contract agreement at anytime. *
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy