Virtual Course Registration Form
Baltimore Win Foundation
What program are you planning to enroll with?
Medical Billing & Coding
INQUIRY ONLY
Student Information
Student Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Phone Number
*
Email Address
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
This section is optional. You may leave it blank if it is not applicable.
Highest Level of School Completed
Name of Last School Attended & Year
Current Occupation
Company Name
Company Phone Number
Supervisor's Name
Write something about yourself
Skills, Talents, and Hobbies
Please upload your Driver's License, State Issued ID or Passport
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Do you have any disabilities, illness, medical conditions, personal problems, etc. that can affect his/her virtual classes/study?
PAYMENT OPTIONS
I will be paying the full $899
I'm requesting a Bi-Weekly Payment Plan ($99 Down-$100 Bi-Weekly X 8 Payments)
I'm requesting a Monthly Payment Plan ($99 Down-$200 per month X 4 months)
EMERGENCY CONTACT
Name
First Name
Last Name
Phone Number
Relationship
Payment Methods
How will you be paying for your virtual course?
Venmo-@baltimorewinfoundation
CashApp-$BaltimoreWinTraining
Square-https://square.link/u/wnJYTBhc
You will receive an email from Alison (our LMS) within 24-48 of payment receipt allowing you to register and begin the training modules. You will also receive emails from us periodically for periodic special live trainings, events and important information. Please call or text 443-472-5707 if there are any issues. Please list any additional information you want to share below
Student Signature
Date Signed
-
Month
-
Day
Year
Date
Print Form
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