New CPR/BLS - Student Registration Form

10000 W. 75th Street, Suite 241
Merriam, Kansas 66204
Tel/Text: 913-708-8323
www.MACOHS.edu

CPR/BLS - Student Registration Form

STUDENT INFORMATION

Confidential

First Name

Middle Name

Last Name

Former Name (if applicable)

Street

City

State/Province

Country

Zip/Postcode

Cell Phone

Birth Date

Social Security No

Do you require special accommodation for any existing health conditions, disabilities, allergies, etc.?

If yes, please specify

How did you hear about us?

Sponsor Information

If you are sponsored by a third-party organization, please provide their details below. For information about how to obtain sponsorship, please visit: Financial Assistance

Are you a sponsored student?

Yes No Not Selected

If yes, Name of Sponsor

Sponsor Email

Sponsor Phone contact

Class Schedule

Class

CPR Course Schedules

Student Signature

Date

Student Declaration:

After clicking "Next" below, you will be prompted to choose your program/course start date on the next screen. Submitting this form does NOT finalize your enrollment. Instructions on how to complete your enrollment will be emailed to you after you select a start date and click "Submit" on the next screen.

I certify that the information I've provided is true and accurate to the best of my knowledge.

Enter the above code

Required