Innovative Health Care Institute Enrollment Request Form
By completing this form, you are requesting
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Email *
First Name and Last Name *
Address: Includes Street Address, city, state, zip code *
Contact Number *
Date of Birth
Program of Interest *
Classes are offered Day, Evening and Weekends, which do you prefer? *
Have you completed the following enrollment requirements?  (Check all that apply)
How did you find out about our program? *
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