Student Course Registration Form

Student Registration Form

Fill out the form carefully for registration
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student E-mail
Mobile Number

Area CodePhone Number
Current Employer/Job Title
Phone Number

Area CodePhone Number
Work Number

Area CodePhone Number
Highest Grade Completed

My Products

Nursing Assistant Training Program. Non-Refundable Registration Fee

Nursing Assistant Training Program$95.00

Non-Refundable Registration Fee

Medical Assistant Training Program. Non-Refundable Registration Fee

Medical Assistant Training Program$200.00

Non-Refundable Registration Fee

Phlebotomy Training. Non-Refundable Registration Fee

Phlebotomy Training$120.00

Non-Refundable Registration Fee

Advanced Nursing Assistant PLUS Phlebotomy . Non-Refundable Registration Fee

Advanced Nursing Assistant PLUS Phlebotomy $150.00

Non-Refundable Registration Fee

Medical Billing and Coding. Non-Refundable Registration Fee

Medical Billing and Coding$175.00

Non-Refundable Registration Fee

EKG Technician. Non-Refundable Registration Fee

EKG Technician$140.00

Non-Refundable Registration Fee

Total $0.00

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

NON REFUNDABLE APPLICATION FEE REQUIRED TO PROCESS THIS APPLICATION. I am an authorized user of the card entered to pay the NONREFUNDABLE registration fee and will NOT dispute the payment with my credit/debit card institution; so as long as the transaction corresponds to the terms indicated in this form. (Please type OK and YOUR NAME in the box below)
Class Start Date (Please check only ONE)
Should be Empty: