Student Registration Form
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Student Name
*
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Address
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Student E-mail
*
Mobile Number
*
-
Area Code
Phone Number
Current Employer/Job Title
Phone Number
-
Area Code
Phone Number
Work Number
-
Area Code
Phone Number
Highest Grade Completed
*
GED Certificate
High School Graduate
College Courses: No degree/certificate
Associate Degree
Certificate: Less than 2 years
Bachelor’s degree or beyond
My Products
*
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Nursing Assistant Training Program
$
95.00
Non-Refundable Registration Fee
Medical Assistant Training Program
$
200.00
Non-Refundable Registration Fee
Phlebotomy Training
$
120.00
Non-Refundable Registration Fee
Advanced Nursing Assistant PLUS Phlebotomy
$
150.00
Non-Refundable Registration Fee
CPR Training Course
$
65.00
BLS/First Aid Certification
Total
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Tuition Payment Method Options
*
AFTERPAY (Invoice will be sent to email)
Payment Plan offered by A&O Healthcare
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)
*
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