REGISTRATION FORM

*****Please Read****** After completing this form, please navigate to our course catalog and select Book Now to successfully register for your desired course by paying the $150 registration fee. A payment plan must be put in place before the start of class for your remaining tuition. You are not registered for a course if you do not pay the registration fee. If you have any questions, please contact our Program Director at 402-406-4644 or admin@prestigehealthedu.com.

First Name *

Last Name *

Social Security Number *

Email *

Phone Number *

Gender *

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Race (used for statistical purposes only):

Course Title: *

Desired Start Date

Student Signature *

By typing your name above, you agree this serves as your electronic signature.

Student Signature Date *

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