2506 Country Club Dr.
870.345.0530
Registration Form
Fill out the form carefully for registration
Student Name
*
First Name
Middle Name
Last Name
Birth Date
*
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Year
Gender
Please Select
Male
Female
N/A
Address
*
Street Address
Street Address Line 2
City
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Postal / Zip Code
Student E-mail
*
example@example.com
Mobile Number
*
Phone Number
*
Work Number
Company
Courses
*
Please Select
Nursing Assistant Training Program
Phlebotomy Technician - In Person
Phlebotomy Technician- Online
Phlebotomy Technician - Fast Paced
Medical Assistant - Hybrid (Online & In Person)
Medical Assistant- Online
CPR - Training dates TBD
Additional Comments
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Registration Fee - Non refundable
Registration fee counts towards the total cost of the program and secures your spot for the course. This registration fee is for the CNA and Phlebotomy Program. Choose this option if you do not want to pay class in full when registering.
$
100.00
CNA
Paid in full on registration. Includes registration fee.
$
700.00
Quantity
1
2
3
4
5
6
7
8
9
10
PBT
Paid in full day of registration. Includes registration fee.
$
850.00
Quantity
1
2
3
4
5
6
7
8
9
10
Registration Fee
$
100.00
Quantity
1
2
3
4
5
6
7
8
9
10
CMA Registration Fee
$
350.00
Quantity
1
2
3
4
5
6
7
8
9
10
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.
ACH Bank Transfer
Afterpay
After submitting the form, you will be redirected to Afterpay to complete the payment.
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