PACIFIC SHORE TRAINING CENTER REGISTRATION FORM
Full Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
Are you older than 18? yes/No
*
COURSES
*
75 HOUR HOME CARE AIDE CLASS (Orientation and safety, Dementia specialty, Mental Health specialty, and Core basic)
Nurse Delegation ( Nurse Delegation core and Nurse Delegation Diabetic)
CPR/FIRST AID
CONTINUE EDUCATION
OTHER
ORIENTATION AND SAFETY SELF STUDY
If you do not find a class in the list, please write it here.በዝርዝሩ ውስጥ ክፍል ካላገኙ እባክዎን እዚህ ይጻፉት።
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