Online Course Student Registration

Online Course Registration Form

Registration Form for Online Courses Only

Basic Information
Online Course Requested*
Please select the desired online course you would like to register for.
Student Name*

First NameLast Name
Social Security Number of Student*
Virginia requirements due to certificate program. Used only in secure formats.
Email Address of Student*
Required. Must be student's email address, not email address of employer.
Student Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number of Student*
Sponsored Employer*
Type "Self Pay" if taking course outside of a sponsored employer.
Email Address of Sponsor*
example@example.com
Phone Number of Sponsored Employer:*
Type "Self Pay" if taking course outside of a sponsored employer.
Billing Address of Sponsored Employer

Street Address

Street Address Line 2 including ATTN Contact

CityState

Zip Code
Online Refreshers;
- After registration, an online course link is email to students weekly on Mondays by 4pm (excluding holidays). Please utilize students' direct email addresses for emails to be sent.
- Once the course is sent out via email, each student has 7 days to access the course. If the course is not accessed in this time the link to the course will expire. (Please check your spam folder if you believe you have not received your course within 3 business days of registering)
- Please allow up to 10 business days for our staff to verify results of the quiz and for results to be graded and sent.
- Results are sent weekly, by the end of the business day on Thursdays. If you have not received your results, please wait until the next Thursday or contact our course contacts:
  - Thomas Bevan, CPhT thomas.bevan@bremorx.com
  - Jamie Coleman, RN jamie.coleman@bremorx.com
32 Hour Medication Management Course;
- After registration, an online course link is email to students within 2 business days. Please utilize students' direct email addresses for emails to be sent.
- Once the course is sent out via email, each student has 7 days to access the course. If the course is not accessed in this time the link to the course will expire. (Please check your spam folder if you believe you have not received your course within 3 business days of registering)
- Upon completion of the online course, students will be prompted to sign up for their in-person review day and then their in-person testing day to complete to remaining portions of the course.
- Students must provide record of completion for thier online learning modules in order to attend any in-person days of class.
I understand the above conditions to Bremo's online courses.*

YesNo
Comments

Credit Card Payment

Online registration requires payment upon registration of the course.*

*Sponsored* 1-Hour Refresher Fee$10.00

Choose only if your residents utilize our pharmacy.

*Non-Sponsored* 1-Hour Refresher Fee$40.00

*Sponsored* 4-Hour Refresher Fee$25.00

Choose only if your residents utilize our pharmacy.

*Non-Sponsored* 4-Hour Refresher Fee$80.00

*Sponsored* 32-Hour Medication Management Fee$65.00

Choose only if your residents utilize our pharmacy

*Non-Sponsored* 32-Hour Medication Management Fee$300.00

Enter coupon

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

Online Course Registration Form