Clone of Student Enrollment & Registration Form – Peach State Medical Institute

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Name* This field is required.

First Name

Last Name

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Phone Number* This field is required.

Please enter a valid phone number.

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Email* This field is required.

example@example.com

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Which program are you enrolling in?* This field is required.

EKG

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Select your preferred class date* This field is required.

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⚠️ Seats are first come, first served. Your seat is NOT reserved until payment is received.

If you haven't done so, please submit your initial deposit of $200.00 on our website: www.peachstatemedicalinstitute.com to secure your seat.

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Will you be using a payment plan?* This field is required.The total tuition for the EKG Training Program is: $1,300.00. After paying your initial deposit of $200.00, the remaining balance of $1,100.00 can be paid via a payment plan option or paid in full. Please indicate if you will be using a payment plan option or paying the remaining tuition of $1,100.00 in full below.

Yes, I will use a payment plan to pay the remaining tuition of $1,100.

No, I will pay the remaining tuition of $1,100.00 in full.

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Payment Plan Options* This field is required.We offer weekly and bi-weekly payment plan options. Please note that your first payment is due on the first day of class. Please contact admissions at 678-602-2907 if you have any questions regarding payments, account balances, or billing. Please select your payment plan option below.

4 weekly payments of: $275.00

2 bi-weekly payments of: $550.00

I will pay the remaining tuition of $1,100.00 in full

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Payment Agreement* This field is required.I understand that my seat is not reserved until a $200.00 deposit is submitted. The initial deposit can be submitted by going to www.peachstatemedicalinstitute.com. I understand that my remaining balance must be paid in full on or before the last day of class.

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HIPPA Agreement* This field is required.I understand that during training I may be exposed to confidential information and agree to follow HIPAA guidelines at all times. I agree to follow HIPAA guidelines.

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Liability Waiver* This field is required.I understand that this training includes hands-on practice and I accept all risks. I release Peach State Medical Institute from liability. I agree to the liability waiver

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I give permission for photos/videos taken during training to be used for educational or promotional purposes.* This field is required.

YESNO

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Student Policy Agreement* This field is required.I agree to follow attendance requirements, payment terms, and all school policies. No refunds after class begins. I agree to all student policies

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Signature* This field is required.