Enrollment Application
$45.00 Application Fee (Non-refundable)
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
My Products
prev
next
( X )
Phlebotomy Technician /Lab Assistant Course
CPR/BLS Included
$
1,140.00
Quantity
1
2
3
4
5
6
7
8
9
10
Phlebotomy Technician Refresher Course
$
920.00
Quantity
1
2
3
4
5
6
7
8
9
10
Clinical Medical Assistant
Includes: Textbook, Certification Fee, & CPR/BLS
$
1,970.00
Quantity
1
2
3
4
5
6
7
8
9
10
DUO Medical Assistant /Lab Assistant Course
Includes: Textbook, Certification Fee, & CPR/BLS
$
2,910.00
Quantity
1
2
3
4
5
6
7
8
9
10
Hybrid Patient Care Technician Course
Includes: Textbook, Certification Fee, & CPR/BLS
$
1,284.00
Quantity
1
2
3
4
5
6
7
8
9
10
Hybrid Home Health Aide Course
Included: CPR/BLS
$
620.00
Quantity
1
2
3
4
5
6
7
8
9
10
Medical Assistant Refresher
Included: CPR/BLS
$
1,120.00
Quantity
1
2
3
4
5
6
7
8
9
10
Phone Number
Please enter a valid phone number.
Course Selection
Please Select
□ Phlebotomy Technician
□ Phlebotomy Tech Refresher
□ Clinical Medical Assistant
□ DUO Medical Assistant & Lab Assistant
□ Patient Care Technician
□ Home Health Aide
Medical Assistant Refresher
Select Course Start Date
-
Month
-
Day
Year
Date
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Upload High School Diploma/GED & Government Issued Identification Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: