Student Registration Form
General Information
First Name
Middle Name
Last Name
Maiden Name
Birth Date
Age Range
...
14-21
22-34
35-54
55-64
65 and over
Gender
...
Male
Female
Non-Binary
Race/Ethnicity
...
American Indian/Alaskan Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian/Pacific Islander
Race/Ethnicity Not Identified
Two or More Races
White (Not Hispanic)
Primary Language
...
English
Other Than English
Street
City
State/Province
...
Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
Armed Forces
Armed Forces Americas
Armed Forces Pacific
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland
North Carolina
North Dakota
Northern Mariana Islands
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Palau
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
N/A
Zip/Postcode
Home Phone
Residency Status
...
US Citizen
Non US Citizen
Cell Phone
Email
Are you former or active U.S. military?
Yes
No
Not Selected
Yearly Income
...
$0 - $ 10,000
$10,001 - $20,000
$20,001 - $30,000
$30,001 and up
Highest Level of Education Received
...
Associate's Degree
Bachelor's Degree
Doctor's Degree
High School Diploma
High School Equivalency
Master's Degree
Postsecondary award, certificate, or diploma (at least 1 but less than 2 academic years)
Postsecondary award, certificate, or diploma (at least 2 but less than 4 academic years)
Postsecondary award, certificate, or diploma (less than 1 academic year)
Are you disabled?
Yes
No
Not Selected
Are you interested in a day or evening schedule?
...
Day
Evening
Registration Information
Program
...
Adult and Pediatric CPR AED First Aid (CPR1)
Adult CPR, AED, and First Aid (CPR 103)
Basic Life Support CPR for the Healthcare Provider (CPR 101)
Clinical Medical Assistant (CCMA3 - CCMA)
Comprehensive Medical Assistant Program (COMP MA1)
EKG Technician (EKGT)
Patient Care Technician (PCT2)
Phlebotomy Technician (PT)
Campus
...
Arnold (Branch)
Florissant (Main)
I have read this document and I understand that my registration is not complete until I pay the specified registration fee, and that my seat in class is not secured until that fee is paid.