EKG Technician Training Registration Form

Are you using SNAP or any form of Tuition Assistance? *

Yes

Which 8 Week EKG Technician Class Are You Interested in Attending?

First Name

Middle Name

Last Name

Maiden Name (If Applicable)

Date of birth

Gender

Male

Female

Address

City

State

Postal code

Email *

Phone *

Driver's License Number (no dashes)

Social Security Number

Race (Required for Background Check

State of Birth (Required for Background Check)

Country of Birth (Required for Background Check)

Which Social Media platform do you use most often?

Have you ever been convicted of a felony or any other crime?

Yes

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 obtain a GED or equivalent education?

Yes

Did you graduate from high school?

Yes

Did you graduate from college?

Yes

Not Applicable

Do you have a learning disability, IEP or 504 Plan? (This will allow us to assist you during the course)

Yes

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

If yes, specify those restrictions or accommodations

Why are you enrolling in the EKG Program?

What size top do you wear?

What size bottom do you wear?

How did you hear about Revived Medical Training Academy?

Emergency Contact Information

Emergency Contact Name

Mobile Phone *