Course Registration Form

Student Enrollment Form

We ask that you please allow 24-48 hours for your email inquiry to be responded to. Please be aware that we respond to emails in the order in which they are received. Thank you for choosing Aspiring Medical Training Institute.
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail
example@example.com
Mobile Number
Date

MonthDayYear
Date
Which course are you interested in?
Select a date for enrollment (Use for Phlebotomy Workshop only) Dates subject to change depending on enrollment.

May 22nd-27th 2023 Days M-F 0800-4:30p Saturday is required from 0800-12pJune 19th-24th 2023 Day M-F 0800-4:30p Saturday is required from 0800-12pJuly 17th-July 22nd 2023 Day M-F 0800-4:30p Saturday is required from 0800-12pAug. 14th-Aug. 19th 2023 Day M-F 0800-4:30pm Saturday is required from 0800-12pNot sure yet.
CPR training, renewal or new start training dates: Class is 0900-1pm Usually held on 3rd Saturday of the month. (Please call to book a group training for 10+ )

May 2024June 2024July 2024July 2024
Are you a citizen of the United States?
Will you use the self-pay option? (We accept all credit cards, sponsorships and Afterpay)
Do you have a high school diploma or GED? (Not a requirement but highly recommended). Must answer.

YesNo
Can you speak and read English fluently? (Requirement)

YesNo
Have you been identified as having a learning disability? (This will not prevent you from enrolling and being accepted)

YesNo
Should be Empty:

Student Enrollment Form