Certification Course Registration Form

Certification Course Registration Form

(Do not complete this for for EMT course)
Student Name

First NameLast Name
Birth Date

MonthDayYear
Gender
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from Physical Address)

Street Address or P.O. Box

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Phone Number
What course are you registering for?
Preferred Method of Contact.

EmailTextPhone Call
If your course requires payment, what form of payment will you be using?

Cash- The day of courseCheck- At least one week prior to course, $50 return check fee will be addedCredit Card or Debit Card- Will be processed through Venmo, due at time of invoice receiptPayment App- Must be Venmo, Cash App, or PayPal; due at time of invoice receipt
Additional Questions, Comments, Concerns.
Should be Empty: