Payment Center Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Student Full Name *Email Address *AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone Number *Reason for Enrollment * Phone File Address Signature * Clear Signature Please sign to agree to the terms of enrollment.Agreement TermsPlease read the following terms before signing the agreement.Checkbox ItemsMulti-Skilled Healthcare Technician Down payment $300.00 – $300.00Mentor program to Colleges/Organization $799 per student – $799.00Prep MA Course – High School/Youth students $499 per student – $499.00Prep Billing/Coding (Must be a Certified Coder) $699 – $699.00Down Payment – $499.00Misc – $25.00Misc – $100.00Medical Assistant Down Payment – $499.00Medical Assistant Balance – $1,000.00Patient Care Tech Down Payment – $499.00Patient Care Tech Balance – $900.00Pharmacy Tech Down Payment – $499.00Pharmacy Tech Balance – $900.00Surgical Tech Down Payment – $999.00Surgical Tech Balance – $3,000.00Uniform – $50.00Lab Kit – $60.00Consultant Services – $99.00Dental Assistant – $1,600.00CPR/BLS – $299.00Acknowledgment *I agree to the termsI have read and agree to the terms stated above.File Upload Drag & Drop Files, Choose Files to Upload Square *CardName on CardSubmit
