Registration / Payment Plans Registration Form Please fill out this form to register for CNA 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 2020 class date are you registering for?Select Date...January 11thFebruary 8thMarch 3rdJuly 5thdates are subject to changeDay or Evening?Select One...DayEveningOnly 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 NowLaterpayment option*select an option...CashCardChoose a Payment Option.*Select One...Option 2: $500 down / 3 weekly installments of $150.00Option 3: $250 down / 3 weekly installments of $250.00Down Payment Price: $500.00 Down Payment Price: $250.00 *Note that not paying later during registration will not secure you a spot in the class. ALL CLASS PAYMENTS ARE DUE BEFORE CLASS STARTS. 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 $960.00 for 7 weeksOption 2: $500 down / 3 weekly installments of $150.00Option 3: $250 down / 3 weekly installments of $250.00Payment Amount* Class Cost Price: $960.00 Down Payment Price: $500.00 Down Payment Price: $250.00 CAPTCHATotal $0.00 PhoneThis field is for validation purposes and should be left unchanged.
