EKG Registration Form

Certified EKG Technician

4-Week Course Registration Form (non-refundable registration fee required)
Name*

First NameLast Name
E-mail*
example@example.com
Date of Birth*

MonthDayYear
Date
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact*

First NameLast Name
High School Attended*
Graduation/GED Year*

MonthDayYear
Date
FacebookGoogleInstagramA friendOther
Saturday 8am-1pm (April 4th)Saturday 8am-1pm (May 2nd)
Payment

Payment Options*

Full Tuition

$1,300.00

Non-Refundable Registration Fee

By choosing this option, you will have 3 remaining payments to complete on a weekly via automatic invoice.

$325.00

Total

$0.00

Credit Card

Apple Pay

Google Pay

Certified EKG Technician