Course Registration Form

Student Online Registration Form

Fill out this online application in its entirety. The email address and phone number provided will be used for all communications.
Student Name*

First NameMiddle NameLast Name
Gender*
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail*
example@example.com
Phone Number*
Current Employer/Job Title
Work Number
Highest Grade Level Completed*
Course Start Date*

MonthDayYear
Date
Select Course*
I certify that my answers on this document are accurate and complete to the best of my knowledge. If I am accepted into the School, I understand that any false or misleading information contained in my application, regardless of time of discovery, may result in my dismissal from the program. I agree to weekly Covid-19 testing if I am not vaccinated and will wear required face mask while on School premises due to the ongoing global healthcare crises. I understand that a non-refundable registration fee is required to process this application. I am an authorized user of the card presented and will not dispute payment with my credit/debit card institution. Please type your full legal name in the box below to certify as your electronic signature.*
Book Course & Training *
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CNA Program Non-refundable Registration Fee
$65.00



Phlebotomy Technician ProgramNon-refundable Registration Fee
$85.00



AHA CPR/AED Training Onsite Hands-on Skills Session
$65.00
We value and appreciate referrals from our students! If someone referred you to our program, please provide their full name below so we can recognize and thank them for sharing this opportunity with you.*

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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Student Online Registration Form