Ava Enrollment Form

Ava Enrollment Form
Select your course and date *
Individual Training Cost: $950

Patient Care Technician Training Cost: $3500
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Date of Birth *

Month Day Year
Date
Email *
example@example.com
Note: If you choose Down payment today, the remaining payments should be made in the office. You can establish a weekly or biweekly payment plan for the remaining amount due.

My Products *

Individual Training - Pay in Full $ 950.00

Individual Training - Down Payment $ 250.00

Patient Care Technician Training - Pay In Full $ 3,500.00

Patient Care Technician Training - Down Payment $ 500.00

Total $ 0.00

How would you want to make the remaining payments (Fill only if you don't pay in full)
Which day of the week would you prefer your remaining payments to be charged (Fill only if you don't pay in full)
How did you hear about us?
Student signature *

Clear
Should be Empty: