1 Personal Information 2 Additional Information 3 Emergency Contact Information 4 Payment Information Training Location*AshlandOntarioWoosterOrrvilleWhich office/location would you like to register for classes with?Name*FirstLastMISocial Security #*Date of Birth*Address*City*State*Zip Code*How Long at this address?*Primary Phone*Secondary PhoneBest Time to Call?*MorningAfternoonEveningEmail* How did you hear about us?*Online SearchFacebookFriend/FamilyPrint AdOnline AdAre you sponsored or do you work in a Long Term Care Facility?*YesNoName of Long Term Care Facility*Address of Facility*Are you eligible to work in the United States?*YesNoDo you have an IEP?*YesNoIf yes you will be required to provide all Individualized Education Program (IEP) paperwork.Can you read and write English?*YesNoHave you ever been convicted of or pleaded guilty to a felony in the past 7 years?*YesNoConvictions need to be reviewed with Program Coordinator prior to starting classPlease Explain*Give date, location, charge, etc Emergency Contact Name*Relationship*Address*City*State*Zip*Primary Phone*Secondary Phone WIA Approved?*NoYesHave you filed for and been approved for WIA (Workforce Investment Act)? You will be required to submit all applicable paperwork for your finical aid to be approved.Payment Options*Deposit OnlyPay for Class in FULL TodayPersonal Payment PlanThe total cost for training is $600, which includes class, books, testing (one time written/skills) CPR/First Aid. A minimum of a $100 non-refundable deposit towards the total cost is required to register for classes unless you've selected a payment plan.Payment Options*Deposit OnlyPay for Class in FULL TodayPersonal Payment PlanThe total cost for training is $600, which includes class, books, testing (one time written/skills) CPR/First Aid. A minimum of a $100 non-refundable deposit towards the total cost is required to register for classes unless you've selected a payment plan.Total Payment Required for today$0.00Finacial Agreement*I AgreeI understand that I am responsible for payment in full before receiving my certification. If for some reason I must withdraw from the class after it has started, I will be able to apply the full balance to another class of my choice at a later date. I also understand that if I am unable to start back into classes after 60 days, I may have to restart the classes from day 1. Refunds will only be given if the class has not started minus a $100.00 deposit. This will allow another student to take the class in your place. All questions have been answered and I understand my financial obligations. Signature* If you have a touch screen device you MUST sign with your finger or stylus. On non-touch enabled PCs or devices please use mouse or touchpad.