New Student Registration
Medical Coding Course
Name
First Name
Last Name
Parent or Guardian (if under 18)
First Name
Last Name
Email
example@example.com
Phone Number
Date of Birth
-
Month
-
Day
Year
Date
Why do you want to take this Course?
Do you have any experience in the medical field?
Do you have any health issues I should know about? (Allergies, acid reflux, vocal injuries, etc.)
What goals would you like to focus on in your course?
Overcoming fear, self doubt, or other barriers in performance
Other
Classes are Wedensday evenings 5-8 pm Every other Saturday 8 am-noon
$150.00 registration fee ,Register by appointment.
Payment options can be paid by below options.
Once per week
Once every other week
pay in full
Other
Is there anything else you’d like me to know?
What is your payment preference? If payment is not received on which you have agreed payment due date a $25.00 late will be added to the invoice. Students cannot attend class until the invoice is up to date per student payment agreement.
PayPal
Cash
Zelle
Square
check
If you can't attend Class , so please let me know at least 8 hours before your Class start. Student is responsible for getting information from a classmate. There are no refunds for cancelled classes. If it can be rescheduled you will be notified by email. Please remember the Class is very demanding attendance is very important.
I have read and agree with the 8 hour policy.
I’d like to stay in touch with you! I promise to only send you emails regarding being a student of my class or information which will have value to you as a student.
Yes, I agree to be added to the email list and I understand I can unsubscribe at any time.
No, I do not want to be added to the mailing list.
Signature
Submit
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