New Student Registration Form

Student Registration Form

General Information

First Name

Middle Name

Last Name

Birth Date

Gender

Street

City

State/Province

Zip/Postcode

Home Phone

Cell Phone

Registration Information

Campus

Program of Interest

Start Date

Time

Education

Please select One:

Date received

Location Received:

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

Chosen Payment Plan

Financial Aid Funding Source

Case Worker’s Name

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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.

Student Signature

(Please print your name)

Date