EMR Skill Weekend Transfer

Course Options
Start Date of Your Original Skill Training Class*
MM slash DD slash YYYY
Available Classes*
Skill Weekend or Evening Skills
Hidden
Alternate Skill Weekend*
Choose a backup spot in an additional Skill Weekend in case a spot does not open up for you in the waitlisted Skill Week.
Student Information
Full Name*
First Last
Email Address*
Enter Email Confirm Email
Alternate Email Address
If you have a additional email address, please enter it here.
Enter Email Confirm Email
Phone Number*
Anything else you'd like us to know?
Payment
Discount Code
Total
$0.00
Hidden
Payment Method (hidden)
Credit/Debit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Agreement & Signature
Online Course Completion Requirement*
- I understand and agree that I will not be allowed to attend my registered Skill Training class if I have not completed and passed the online portion of the course one week before the first day of class.
Refund Policy*
- I understand and agree that there is no refund of Skill Training tuition nor any refund of Skill Training Transfer Fee under any circumstances as documented in the TERMS AND CONDITIONS
Terms and Conditions*
- I understand and agree to the TERMS AND CONDITIONS
Hidden
Signature of Student
By typing my first and last name below, I verify understanding and agree to the terms and conditions. I also verify that the person completing this form is the student enrolling in the course.
First Last

EMR Skill Weekend Transfer

Course Options

Student Information

Payment

Agreement & Signature