REGISTRATION FORM



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central sterile processing education REGISTRATION FORM

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|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: |

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|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 | |

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|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. |

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|Remit Payments to |

|Charles Walker |

|P.O. BOX 284 |

|Rancocas, N.J. 08073 |

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|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) |

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|IN CASE OF EMERGENCY |

|Name of local friend or relative (not living at same address): |Relationship to participant: |Home phone no.: |Work phone no.: |

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| |Participant /Guardian Signature/Authorized Signature | |Date | |

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