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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Date of birth* 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** Yes No if 'Yes' please explain Have 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?** Yes No if 'Yes' please explain What 2023-24 class date are you registering for?*January 9th-February 27th (Tuesday)January 19th-March 8th (Friday)March 12th-April 30th (Tuesday)March 22nd-May 10th (Friday)May 14th-July 2nd (Tuesday)May 24th-July 12th (Friday)July 16th-September 3rd (Tuesday)July 26th-September 13th (Friday)September 17th-November 5th (Tuesday)September 27th-November 15th (Friday)November 19th-January 7th (Tuesday)November 29th-January 17th (Friday)dates are subject to changeOnly 8 Students per class. First come first served. Date* MM slash DD slash YYYY *Note that not paying after registration will not secure you a spot in the class. Please proceed to payment from the confirmation page. ALL CLASS PAYMENTS ARE DUE BEFORE CLASS STARTS.Class Cost Price: CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.