Registration Form
Fill out the form carefully for registration
Student Name
First Name
Middle Name
Last Name
Birth Date
Please select a month
January
February
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Month
Please select a day
1
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Day
Please select a year
2024
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Year
Gender
Please Select
Male
Female
N/A
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student E-mail
example@example.com
Mobile Number
Courses
Please Select
Private Petite First Aid Course
Private Confidence Course
Private Petite First Aid Course | Private Confidence Course
Additional Comments
Private – please list the number of participants you are planning to host this course for & the location you wanting to have it at (house address). **Payment for privates will need to be paid in full 7 days prior to workshop & a $100 deposit at booking time which will go to the overall cost of the day. An email confirmation will be sent to confirma all details. Please select the preferred date you are wanting the course.
Preferred Date & Time of Course
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Signature
Submit
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