McKallen Medical Training EKG Course Registration Form

McKallen Medical Training

EKG Class Registration Form
Your Name:*

First Name Last Name
Email Address: (Gmail preferred)*
Email
SSN:*
example: 123-25-9870
Date of Birth*

MonthDay Year
MM-DD-YYYY
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number:*

Area Code Phone Number
High School:*
Name of School
GED/Dipolma*

YesNostill enrolled in High School
Year of GED/Diploma completion*
Year
Phone Number*

Area Code Phone Number
Start Date*
Do you have access to a computer, laptop, or Mobile phone to receive and complete assigned coursework?*

YesNo
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 incomeYou're receiving disability financial assistanceYou are currently homelessYou did not complete high schoolYou are currently in foster careYou recently aged out of foster careNone of the above apply to me
How did you hear about McKallen Medical Training?*

Security Deposit

Course Price$200.00

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

Credit Card

Should be Empty: