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STEP 1 of REGISTRATION

Class date enrolling in (month/Day/Year):
Full Name:
Date of Birth:
Street Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
In Case of Emergency Notify:
Emergency Phone Number:
How did you hear about us:
If Other, where did you hear about us:
Select one of the following:
For Sponsoring Agency Only: To comply with State
Regulations, the following information must be completed.
Sponsoring Agency Facility:
Sponsoring Agency Contact Person:
Sponsoring Agency Contact Number:
I have read the student policy agreement:
 yes
Initials:
Todays Date (month/Day/Year):
STEP 2 of REGISTRATION
After you have submitted the registration form
please select payment option and pay below:

Payment Options
Option #1
$350 payment in fullOption #2
Payment Plan Available:
$50.00 Due at Registration
$200.00 Due 1st Day of class
$100.00 Due before or on last day of class
Total $350.00

*book and lab fees included