Medical Assistant Registration Form

Medical Assistant Registration Form

Register to become a medical assistant by providing your personal and educational information.
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you at least 18 years of age or older?
Do you have a high school diploma or GED?
What size scrubs do you wear?
Student orientation is required. Will you be able to attend?
Where did you hear about us?
Please upload your id and social security

Cancelof

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 national certification exam. 4% processing fee will be added.

$104.00 Quantity
Item subtotal:

Total

Credit Card

By signing below I authorize permission of M&A The 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 or disclose or falsifying information could result in dismissal from any course.
Signature
Should be Empty:

Medical Assistant Registration Form

*

Credit Card