New Student Registration Form

Student Registration Form

General Information

First Name

Middle Name

Last Name

Birth Date

Street

City

State/Province

Zip/Postcode

Home Phone

Cell Phone

Registration Information

Program

Campus

Education

Payment Information

All Registration forms must be received prior to the start of the selected class in order for your seat to be guaranteed in class. Registration fees are non-refundable after 5 days of receiving your registration form/payment. All forms of payment are accepted.

Mail checks/money orders payable to: Bell-Brown Medical Institute

Pay online at www.bellbrownmedicalinstitute.com

By mail: Send payments to Bell-Brown Medical Institute 470 Howdershell Rd. Florissant, MO 63031

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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.