Allied Health Refresher Course
Enrollment Questionnaire
Name
*
First Name
Last Name
Date of Birth
*
Email Address
*
Phone Number
*
Please enter a valid phone number.
Which refresher course are you interested in?
*
Medical Assistant
Phlebotomy
Where did you complete your initial Allied Health program training?
*
Name of School/Program
What year did you graduate/complete your program?
*
Have you taken a refresher course before?
*
No
Yes
If yes, when and where?
Have you taken a national certification exam for your Allied Health profession?
*
No
Yes
If Yes, is your certification still current?
*
No
Yes
Why do you want to take the refresher course?
*
Preparing to re-enter the Workforce
Preparing to Renew Certification (expired in the past 2 years)
Preparing to Take the Initial Certification Exam
Preparing to Retake the Certification Exam
You will need to provide documentation showing you've successfully completed an Allied Health training program prior to registering for this related Refresher Course. Please upload a copy/photo of your completion certificate, transcript or other proof of documented completion. If it is not included/attached to this questionnaire, a copy is required to be presented at the time of registration.
*
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