REGISTRATION FORM
1
central sterile processing education REGISTRATION FORM
| |
|Today’s date: |Instructor: Charles Walker, MBA, CRCST, CHL, ORT |
|PARTICIPANT INFORMATION |
|Last name: |First: |Middle: |θ Mr. |θ Miss |Marital status (circle one) |
| | | |θ Mrs. |θ Ms. | |
| | | |Single / Mar / Div / Sep / Wid |
|Is this your legal name? |If not, what is your legal name? |(Former name): |Birth date: |Age: |Sex: |
|θ Yes |θ No | | | / / | |θ M |θ F |
|Street address: |State ID #: |Home phone no.: |
| | |( ) |
|P.O. box: |City: |State: |ZIP Code: |
| | | | |
|Occupation: |Employer: |Employer phone no.: |
| | |( ) |
|Chose the class because/Referred by (please check one box): |θ | |θ Union |θ Hospital |
| |Name | | | |
|θ Family |θ Friend |θ Close to home/work |θ Yellow Pages |θ Other | |
| |
|class INFORMATION |
|Registration: Please fill out the registration form and return it to the open registration sessions. Registration session dates are available on the registration |
|hotline at 609-668-9164. (Methods of Payment – Certified Bank Check, Personal Check, Cash, or Money Order). If we receive a returned check from the bank for a |
|payment you are responsible for the original amount of the check plus a $35 bounced check fee. |
|Refund Policy: No refunds are given after the textbooks have been ordered. Textbooks are ordered after the first class session and are handed out the second class |
|session. Classes are conducted on every Saturday from 9am to 2:00pm. |
| |
|Remit Payments to |
|Charles Walker |
|P.O. BOX 284 |
|Rancocas, N.J. 08073 |
| |
|TRAINING LOCATION: Robert Wood Johnson University Hospital Fitness Center,3100 Quakerbridge Road, Hamilton, NJ 08619 |
|Person responsible for bill: |Birth date: |Address (if different): |Home phone no.: |
| | / / | |( ) |
|Occupation: |Employer: |Employer address: |Employer phone no.: |
| | | |( ) |
|Is Payment covered by your Employer? |θ Yes |θ No | TRAINING COURSES |
| | | |Certified Registered Central Service Technician (CRCST) - $ 2,000.00. (Must be a high school |
|Is Payment covered by your Union? | | |graduate or have a GED) |
| |θ Yes |θ No | |
|Is Payment covered by Parent/Guardian? | | | |
| | | |Certified Healthcare Leadership Review Course (CHL) - $ 3,500.00 (Only those with CRCST |
| |θ Yes |θ No |certification and 6 month to 1 year work experience are allowed to enroll) |
| | | | |
| | | |Certified Endoscope Reprocessor (CER) - $3,500.00 (Only those with CRCST certification and 6|
| | | |month to 1 year work experience are allowed to enroll) |
| |
|IN CASE OF EMERGENCY |
|Name of local friend or relative (not living at same address): |Relationship to participant: |Home phone no.: |Work phone no.: |
| | |( ) |( ) |
| |
| | | | | |
| |Participant /Guardian Signature/Authorized Signature | |Date | |
| | | | | |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- nevada business registration form online
- medical marijuana registration form pa
- vanguard account registration form pdf
- new patient registration form template
- patient registration form microsoft word
- patient registration form word document
- medical patient registration form template
- patient registration form word document free
- patient registration form template
- business registration form jamaica
- nj dmv registration form pdf
- combined employers registration form oregon