CNA Course Registration Form

Student Registration Form

Fill out the form carefully for registration
Student Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Student E-mail*
example@example.com
Mobile Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Education/Enrollment
Highest Level of Education ?*
Are you at least 16 years old?*
Have you ever been convicted of a felony ?*
Race:(required for background screening)*
Please select the course you are wanting to register for.*
Student orientation is required will you be able to attend?*
What size scrubs do you wear ?*
How did you hear about us ?*
By signing below I authorize permission of M&A Academy of Caregiving to run a criminal background check. I certify that all answers given in this application are accurate to the best of my knowledge. I understand that failure to disclose or falsifying information could result in my dismissal from any course.
Signature*

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Student Registration Registration fee is required to reserve your seat and is non-refundable. The remaining balance must be paid in full prior to the completion of course. Failure to do so , will result in delay in receiving certificate of completion and taking state exam. 4% processing fee will be added.

$100.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card

Should be Empty:

Student Registration Form

Education/Enrollment

Credit Card