Pre-Registration Ethical Issues in Healthcare

Pre-Registration Ethical Issues in Healthcare

Pre-Registration
Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
County of Residence
Phone Number *

Area Code Phone Number
Date of Birth *

Month Day Year
Date
E-mail *
Are you a resident of Maine? *

Yes No
Are you a US citizen? *

Yes No
Ethnic Group *

Not Hispanic/Latino Hispanic/Latino
Race *

American Indian or Alaska Native Asian Black or African American White Native Hawaiian or Other Pacific Islander
Gender *

Male Female Other
Education (highest grade completed) *

No HS Diploma/GED/ or HiSet HS Diploma, GED, or HiSet Some college/no credential Associate's degree Bachelor's degree Master's degree of higher
Are you currently employed? *

Yes No
If Yes, who is your employer? *
If so, are you currently employed part-time? *

Yes No
How did you hear about this course? *

Newspaper Email Newsletter Facebook Word of Mouth
Do you agree to receive SMS text messages regarding the course?

Yes No
I certify that all information on this application is accurate and complete.
Signature *

Clear
Should be Empty: