Student Full Name
*
First Name
Middle Name
Last Name
Student Enrollment Form
Fill out the form carefully for registration
Birth Date
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Gender
*
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Address
*
Street Address
Street Address Line 2
City
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Postal / Zip Code
Student E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Work Number
-
Area Code
Phone Number
Student Job Occupation
*
Emergency Contact Information
*
Emergency Contact Number
*
-
Area Code
Phone Number
Courses
*
AHE Program
Medical Assistant
Medical Assistant Combo
Phlebotomist Technician
CPT Workshop (JAX Florida)
Phlebotomist Technician Workshop
How Many Years Of Healthcare Experience?
*
0
1
2
3
4
5
6
7
8
9
10+
Reference
Desired Course Schedule.
*
Weekday Night Class
Weekend Day Class
Online With (On-site Clinicals)
Please Indicate The Course Month Below.
Please Place Your Course Date Below.
*
List Previous Healthcare Skills
Please Take A Copy Of Student Identification
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of
Please Take A Copy Of Your GED Or High School Diploma
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of
Photo/Video Consent Form
As part of our commitment to celebrating student achievements and promoting our educational programs, Med Care Pro LLC requests your consent to capture and use photos and/or videos of you during class sessions, hands-on training, and graduation ceremonies. These images may be featured on our website, social media platforms, promotional materials, or other educational resources. Your participation is completely voluntary, and we respect your privacy. If you agree to grant us permission, please complete the photo consent form during registration. Should you have any concerns or wish to opt out, please inform us in writing. We appreciate your cooperation and look forward to supporting you on your educational journey!
*
Please Select
Yes
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New Student Deposit Instructions:
If you have already made the payment for your deposit there is no need to fill out that section again. Instead, proceed to complete the new student registration form. Once you have finished the registration process, you will receive an email welcoming you as a new student. To ensure a hassle-free enrollment, it is essential to have a card on file. This can be done by filling out a bank draft authorization form. The payment options for your course tuition must be settled before the start of classes to ensure that you are fully enrolled. We understand that the enrollment process can be overwhelming, but we are here to help you every step of the way. If you have any questions or concerns, please do not hesitate to contact us. Our team is dedicated to providing you with the support you need to succeed in your academic journey. We look forward to welcoming you as a new student and helping you achieve your goals.
Payment Schedule
*
Weekly
Biweekly
Pay In Full
Half
New Student Deposit & Payment Options
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Medical Assistant Deposit
$
50.00
(This is a nonrefundable deposit of $50.00. The deposit will go towards your tuition and hold your spot.)
Medical Assistant Combo Deposit
$
50.00
(This is a nonrefundable deposit of $50.00. The deposit will go towards your tuition and hold your spot.)
Phlebotomy Technician Deposit
$
50.00
(This is a nonrefundable deposit of $50.00. The deposit will go towards your tuition and hold your spot.)
Phlebotomy Technician Workshop Deposit
$
50.00
(This is a nonrefundable deposit of $50.00. The deposit will go towards your tuition and hold your spot.)
Phlebotomy Technician Workshop (Full Amount)
$
605.00
This includes a $50 deposit & $555.00 Phlebotomist Technician Workshop Course Tuition.)
Phlebotomy Technician (Full Amount) Summer Deal
$
605.00
This includes a $50 deposit & $555.00 Phlebotomist Technican Course Tuition Summer Special.)
Medical Assistant (Full Amount) Summer Deal
$
905.00
(This includes a $50 deposit & $855.00 Medical Assistant Course Tuition Summer Special.)
Student Paid In FULL AMOUNT Medical Assistant
$
1,305.00
(This includes a $50 deposit & $1255.00 Medical Assistant Course Tuition.)
Student Paid In FULL AMOUNT Phlebotomy Technician
$
1,005.00
(This includes a $50 deposit & $1,005.00 Phlebotomy Technician Course Tuition.)
Certification Exam Fee
$
215.00
Certification Exam Fee 2
$
215.00
Enter coupon
Apply
Total
$
0.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Afterpay
After submitting the form, you will be redirected to Afterpay to complete the payment.
I ________, confirm that I have completed the Photo Consent Form and agree or not agreed to allow Med Care Pro LLC to capture and use photographs and/or videos of me during class sessions, hands-on training, and other activities conducted within or associated with Med Care Pro LLC facilities. I understand that these images may be used for educational, promotional, and marketing purposes, including but not limited to the institution’s website, social media platforms, and printed materials. I acknowledge that my participation is voluntary and that I may withdraw my consent at any time by providing written notice to Med Care Pro LLC. I understand that opting out will not affect my enrollment or participation in the program.
*
Full Name
*
First Name
Last Name
I verify the accuracy of all my provided information and confirm that it is not false. As a student, I consent to either placing a card on file or making full payment. I acknowledge that a late payment will incur a $25.00 late fee. I confirm my understanding that the deposit is nonrefundable and cannot be returned.
*
Full Name
*
First Name
Last Name
Thank You For Accepting Us !
Greetings! We are delighted to inform you that you will soon be receiving a welcome email for new students. This email will contain comprehensive information about your courses, including details about the curriculum, study materials, and our school's policies and standards. Additionally, you will find an invoice arrangement for your convenience, allowing you to make weekly or biweekly payments. Furthermore, we kindly request that all students carefully review and adhere to our school contract to ensure a smooth and successful academic journey, while also avoiding any potential consequences. We look forward to welcoming you to our institution and supporting you throughout your educational experience.
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