Enrollment Form

By filling out the form you understand that Alliance Health Care Institute or it's representatives will utilize this information to contact you to provide more information about Alliance Health Care Institute programs by a variety of methods including phone (both mobile or home, dialed manually or automatically), email, mail, and text message. Additionally, calls are monitored or recorded for quality assurance.

Name

First Name

Last Name

D.O.B

MM

DD

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Program

Time

Date

Start Date of Class, Please pick a date from our current Calendar

MM

DD

YYYY

High School Diploma?

By clicking "Submit", you are giving your express written consent for and authorize Alliance Health Care Institute to contact you regarding our educational programs and services using email, surveys, telephone or text – including our use of automated technology for placing calls or texts – to the wireless number you provided on this form or any subsequent wireless number you provide. This consent is not required for enrollment and you may contact us directly at 1-866-475-1138.