Course Registration Form

Registrant's Name *

First

Last

Registrant or Address

Email Address *

Choose The Desired Course *

If you need to choose multiple course, please submit the form for the number of courses you want.

Phone Number *

Preferred Course Start Date *

Please choose the date that you are available, and if we can't train you on that date we will propose alternative dates.

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency Contact Name *

First

Last

Emergency Contact Phone *

Emergency Contact Email *

Please confirm the following items *

I confirm that I met all the pre-qualifications to this course (If requested, student will need to provide their pre-requisites)
I understand that the course deposit is non-refundable if the request is 48h before the start date of the course (Please see course cancellation page)
I understand that I need to be present for my course for the required dates
I understand that my course date will depend on the school availability

I want to have my course on a day that Reimagine Clinic is off, either a Sunday or a Monday (200$ extra will be applied) *

Course Deposit (500$+tx) *

Price: $574.86

Square *

Card

Name on Card

Signature *

Clear Signature