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Enrollment Form

Step 1 of 4

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Program Of Interest
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Tell us a little about yourself:
Name*
First Last
Nickname (if applicable)
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Gender
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- Female
Date of Birth

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Are you a Canadian citizen?*
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List Your Alien Status Or Citizenship

Emergency Contact Info:
Emergency Contact Name
First Last
Emergency Contact Relationship
Emergency Contact Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact Home Phone
Emergency Contact Work Phone

Education Background
High School
High School Address
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Graduation or GED Date
Other Education
Other Education Address
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Other Education Completion Date

Employment Background (if applicable):
Current Employer
Work Type
Current Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Current Employer Phone
Typing Speed
Do you have any medical training?*
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Do you own a computer?*
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Do you have access to a computer?*
- Yes
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Computer Experience (Check all that apply)
- Windows
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- Word
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- Access
- HTML
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How did you hear about this program? Please be specific.
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Please check the boxes below to agree, then hit Submit Your Enrollment.
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- I have read and agree with the Enrollment Agreement
Do not hit the Back button. In a few moments you will be directed to Step 3, the Payment Page. If you have already paid with your Enrollment Advisor, please exit this page now.

For questions while filling out this form or making payment, call us toll free 888-838-9788. We're also available live when the "Chat Now" box is showing in the bottom right hand corner.

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