Department of Health Education – Program Registration

PROGRAM REGISTRATION

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Program Selection

Which program are you applying to enroll in?

Personal Details

Name

First

Last

Gender

Date of Birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Proof of Address

Click or drag a file to this area to upload.

Please upload a photo of a utility bill with your name (no older than 3 months)

Email Address

Phone Number

Mobile Number

Country of Citizenship

Do You Reside in Trinidad & Tobago?

Select Your Form Of Identification

ID / Driver's Permit / Passport Number

Please Attach Your Photo

Click or drag a file to this area to upload.

Other Details

Are You An Employee at St. Augustine Private Hospital?

Are You Currently Employed?

If Yes, Please State Name of Company

Company Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Education

Secondary School Name

When Did You Attend?

Please State Your CSEC/O’Level Subjects And Grades

Other Education

Institution Name

When Did You Attend?

Please State Your Certificates Or Accomplishments

applying Mobile &

Please Attach Your Certificates

Click or drag files to this area to upload. You can upload up to 5 files.

References

Please provide 2 References

Name

First

Last

Relationship

Phone

Name

First

Last

Relationship

Phone

Department of Health Education – Program Registration

PROGRAM REGISTRATION

Program Selection

Personal Details

Other Details

Education

Other Education

References

Need Further Assistance?

Call Us

(868) 216-7274

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