You can always press Enter⏎ to continue
Welcome to Dominion Health Education Center
Please fill out and submit this form.
START
1
Medication Aide Board of Nursing Mandatory 8-hour Review
Previous
Next
Submit
Press
Enter
2
Medication Aide State Board Review
Previous
Next
Submit
Press
Enter
3
Student Name
*
This field is required.
First Name
Middle Name
Last Name
Previous
Next
Submit
Press
Enter
4
Gender
*
This field is required.
Male
Female
N/A
Male
Female
N/A
Previous
Next
Submit
Press
Enter
5
Student's E-mail
*
This field is required.
Please DO NOT use work or school email!
Previous
Next
Submit
Press
Enter
6
Student's Phone Number
*
This field is required.
Area Code
Phone Number
Previous
Next
Submit
Press
Enter
7
Please upload a picture of your government issued picture ID ( drivers license or passport)
*
This field is required.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
Previous
Next
Submit
Press
Enter
8
Is someone else using their credit card to register the student for class? If so, please provide credit card owners First and Last Name, Address and Phone Number. If not, please write N/A
*
This field is required.
Previous
Next
Submit
Press
Enter
9
Cardholder ID
In an effort to protect against fraud, If cardholder is not the student, please upload cardholders drivers license.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
Previous
Next
Submit
Press
Enter
10
Please read and sign- By signing this contract, you agree that all information provided is true, accurate, and complete. You agree to the payment terms of this contract. You agree to all terms of this agreement, including, but not limited to, the Electronic payment authorization and recurring charges authorization(if you have elected to pay by recurring electronic funds transfers) when you sign this agreement. By signing this agreement, you acknowledge you are the cardholder or have permission to use the credit/debit card used at the time of registration. If you are a no-call no-show , you will not be eligible for a refund. PLEASE SIGN YOUR FULL NAME
*
This field is required.
Clear
Previous
Next
Submit
Press
Enter
11
Select tuition.
*
This field is required.
prev
next
( X )
My Bag
0
My Bag
Back to list
Great Product Name
$20
Quantity:
1
Size:
Small
Remove
Edit
Great Product Name
$20
Quantity:
1
Size:
Small
Remove
Edit
Great Product Name
$20
Quantity:
1
Size:
Small
Remove
Edit
Great Product Name
$20
Quantity:
1
Size:
Small
Remove
Edit
ORDER SUMMARY
Total cost
USD
MEDICATION AIDE STATE BOARD REVIEW (Online Course)
$
250.00
+
Remove
Edit
Back
MEDICATION AIDE REVIEW (8 HOURS) Mandated by the VBON
$
250.00
+
Remove
Edit
Back
Credit Card
First Name
Last Name
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
11
See All
Go Back
Submit