STEP #2


Please note: All information asked is State Required.

            Start Date:.........

 
          First Name:........  
          Last Name:........  
          Gender:..............  
          Birth Date:......... //  
     
       Phone:................ () -  
          Address:.............  
          City:....................  
          State:..................  
          Zip Code:...........  
          Email:.................  

          Education:..........  
          Race:..................  

            Hispanic:............

 
          Disability:............. YES NO  

Have you been registered as a nursing assistant in       Washington State before?........................
YES NO
How were you referred to this school?................

 

IN CASE OF EMERGENCY

 

Name:.. Phone:..() -



 I am in agreement to the (5) 8-hour facility clinical days.
 

By submitting this link you hereby acknowledge the above is filled
out truthfully to the best of your knowledge, and you are  responsible
for any false information given.

(This is a contract for which you will be held responsible to pay.)

Students must register for either the AM or PM class

Students will be assigned to attend facility-based clinical training
hours & must be available to attend.

Schedules are not changed for another school obligations

Payment applies to only the class being applied for on this receipt.
No credit to another session.

Cancellations must occur within 5 days of signing this enrollment
contract or registering on-line for consideration of a refund of
the reservation fee, or if student is not accepted by the school.


Cancellations must occur within the 5 days of signing/registering
and/or a minimum of 24 hours prior to the start of the session.

A stop-placement on a check payable to MEDPREP does not prevent
the payment of the reservation fee plus the bank fee of $35.00
from being due to the school if initiated after the 5th day of signing
the contract, closer than 72 hours prior to the start of the session,
and/or once the class has started. The amount due can also include
any costs to initiate debt-collection, legal fees, and/or court proceedings
as necessary. (Should a refund be due to student the non-refundable
deposit amount, withdrawal processing fees, tuition at $36.25 per day,
photo & badge processing fee's and/or any other penalties/expenses
shall be deducted before the balance of funds are returned to student
within 30 days of the date of the school receiving a written (mandatory)
official withdrawal notice from the session for which registered.)

This enrollment form further notifies the person signing that a certificate
of training completion will be withheld for incomplete training hours.
Any missed time requires completion prior to the end of the session
of registration or the student will be required to return to the next
available session as space allows at an hourly rate of $20.00. This payment
becomes due prior to the return to class.

There is no refund after the close of the first Thursday of the session.
Greater than 50% of theory & skills demonstrations have been completed.
 

Note: All fields are required to be filled in, to continue to the next step!


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