Training Class Registration Form

Training Class Registration
Student Name

First NameLast Name
Birth Date

MonthDayYear
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Employer/Facility Name
Select Your Training Class
Select Your Level One Medication Aide Class Date
Select Your Level One Medication Aide Biennial Update Class Date
Select Your Insulin Administration Class Date
Additional Comments
EDL Screening Verification

All prospective students are required to undergo an Employee Disqualification List (EDL) screening before enrollment can be confirmed. By submitting this registration form, you authorize Ultimate Care Health Services to conduct an eligibility screening through the Missouri Department of Health and Senior Services (EDL) Employee Disqualification List. Enrollment is subject to successful verification.
EDL Screening Consent
Tuition Payment & Refund Policy

Tuition is non refundable for student cancellations or failure to attend class. If Ultimate Care cancels a class, students will be offered the option to reschedule.
After submitting this form, you will be automatically redirected to our secure payment page to pay your tuition.
Should be Empty:

Training Class Registration