QMA Registration Form QMA Registration Form Please fill out this form to register for QMA classes Class holds 16 students, clinical holds 8 students days and 8 evenings. Once class is filled up you will not be able to register for this class, but you may register for any other date.Name First Last Email Address Street Address City State / Province / Region ZIP / Postal Code PhoneDate of birth Date Format: MM slash DD slash YYYY Highest Grade Completed*Less than high school graduationHigh School GraduateGEDSome Post H.S., no degree or certificateAssociate DegreeCertificateBachelor Degree or AboveHave you ever been convicted of any crime*YesNoif 'Yes' please explainHave you ever had any license, certificate, registration or other privilege to practice a health care profession denied, revoked, suspended or restricted by a state, federal or foreign authority?*YesNoif 'Yes' please explainWhat 2021 class date are you registering for?Select Date...January 12thMarch 23rdMay 18thJuly 27thdates are subject to changeOnly 8 Students per class. First serve first come. Date Date Format: MM slash DD slash YYYY Would you like to pay now to secure a seat in the class or later?*Pay NowLater*Note that not paying later during registration will not secure you a spot in the class. I want to...*Select Options...Make a one time paymentSelect a Payment OptonChoose a Payment Option.*Select One...Option 1: A One time Payment of $1000.00 for 9 weeksOption 2: $400 down / 3 weekly installments of $135.00Payment Amount* Class Cost Price: $1,000.00 Down Payment Price: $400.00 Total $0.00 CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
