McKallen Medical Training CNA Class Registration Form

McKallen Medical Training CNA Course Registration

Approved American Red Cross Nurse Aide Training Provider
Your Name: *

First Name Last Name
Email Address: (Gmail preferred) *
Email
Date of Birth *

Month Day Year
MM-DD-YYYY
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number: *

Area Code Phone Number
Emergency Contact *

First Name Last Name
Phone Number *

Area Code Phone Number
Program Option: *
* CNA Clinical Location (Please Choose One) *

Ontario Big Bear Community Hospital Riverside Loma Linda Van Nuys Northridge Woodland Hills
Method of Tuition Payment: *

Credit/Debt (1 Payment) I am interested in AfterPay Tuition options (4 payments interest free) I am interested in scholarship opportunities ( Ontario or Riverside)
Start Date *
Textbook Preference *
Uniform Style *
Uniform Size- TOP *

X-Small Small Medium Large X-Large 2X-Large
Uniform Size- PANTS *

X-Small Small Medium Large X-Large 2X-Large 3X- Large
Do you have access to a computer, laptop, or Mobile phone to receive and complete assigned coursework? *

Yes No
Have you ever been convicted of a crime? *

Yes No
If so please describe:
You may be eligible for financial aid if you are between 16-24 years old and are experiencing one or more of the following: *

You qualify as low income You're receiving disability financial assistance You are currently homeless You did not complete high school You are currently in foster care You recently aged out of foster care None of the above apply to me
How did you hear about McKallen Medical Training? *

My Products *

Course Deposit $ 150.00

Three-Day Cancellation: An applicant who provides written notice of cancellation within three (3) business days, excluding weekends and holidays, of executing the enrollment agreement is entitled to a refund of all monies paid, excluding the $150 non-refundable registration fee.

Total $ 0.00

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McKallen Medical Training CNA Course Registration

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