Medical Class Registration Form


Your Name:(* Required)    

Street:                             

City:          State:         Zip:  

Male: [   ]     Female: [   ]       Home Phone:  

Your E-mail Address: (* Required)   

Emergency Phone:        Emergency Contact:  

Your reason for wanting to take this class:



Do you have any medical background?    Yes        No

If Yes, please describe:



How did you hear about us?



From time to time PRNMED and Medical Corps puts pictures of the class on our web site.
If the occasion arises, may we post such images if you are in the picture?         Yes        No

How would you like your name printed on your certificate?


Anything else you'd like us to know? Or anything you'd like to ask?





__________________________________________________________________________________________
                          Signature                                                                                   Date


Please print out this form and send it with your $165 deposit check to: David Turner
PRNMED
Box 1319
Exton, PA 19341
The per/person tuition balance of $200.00 must be received no later than 14 days prior to the class date.

Refunds: If for any reason you wish a refund at any time it will be granted up until 7 days before class. After that time
the deposit will not be refunded unless there are special circumstances as determined by the staff.