ALS/BLS Module Registration

Thank you for your interest in attending the provide module course.
To reserve your seat, please fill out the information below.
Provider Level *
Payment Option *
By signing this form you take responsibility in committing to the course selected above. You understand payment is due four (4) days before the date of the class and that you WILL NOT be refunded money. If class is reschueduled, you will be able to take a class without payment again. "No shows" will not be refunded. 
For all checks returned there will be a $30 fee. 
For all credit and debit cards used there will be a $1 processing fee per transaction. 
Signature *
clear
Registration and payment must be complete four (4) days prior to scheduled class date.
Once registration is complete, The student will receive an invoice including instruction on how to pay via check or card. For all returned checks there will be a fee of $30.
If using a card, there will be a $1 processing fee.
Powered byFormsite