Medical Billing and Coding Training Registration Form
Are you using SNAP or any form of Tuition Assistance?
Yes
No
16 Week Medical Billing and Coding Class Are You Interested in Attending?
July 29 , 2024-October 18, 2024
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First Name
Middle Name
Last Name
Maiden Name (If Applicable)
Date of birth
Please upload a copy of your state or government issued ID, Social Security Card or Work Visa, proof of covid vaccination and any other enrollment documents. If you are not able to upload them, please bring the documents with you on Mandatory Orientation day.
Have You Received the Covid Vaccination
Yes
No
Do you have proof of your Covid Vaccination?
Yes
No
Do you have documentation of a medical or religious exemption for your Covid Vaccination?
Yes
No
Gender
Male
Female
Address
City
State
Postal code
Email
*
Phone
*
Are you at least 18 years of age?
*
Yes
No
Are you a citizen of the United States?
*
Yes
No
Driver's License Number (no dashes)
*
Social Security Number
*
Race (Required for Background Check
*
African-American
Asian
Caucasian
Hispanic/Latino
Native American
Pacific Islander
Mixed Race
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State of Birth (Required for Background Check)
*
Country of Birth (Required for Background Check)
*
Which Social Media platform do you use most often?
*
Facebook
Instagram
Twitter
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Have you ever been convicted of a felony or any other crime?
*
Yes
No
If yes, please include specific information including the date of felony charge, nature of felony, which court and final outcome. Submit copies of the court documentation is available
Court Documentation
Did you graduate from high school?
Yes
No
Did you obtain a GED or equivalent education?
Yes
No
Did you graduate from college?
Yes
No
Not Applicable
Do you have a learning disability, IEP or 504 Plan? (This will allow us to assist you during the course)
Yes
No
Please explain, if applicable
Do you have any physical condition(s) or any other condition(s) which would limit your ability to perform essential job-related functions?
Yes
No
If yes, specify those restrictions or accommodations
How did you hear about Revived Medical Training Academy?
Social Media
A Friend
A Relative
SNAP
Other
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Why are you enrolling in the Clinical Medical Administrative Assistant Program?
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What size bottom do you wear?
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Large
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Emergency Contact Information
Emergency Contact Name
Mobile Phone