Your Name:(* Required)    

Street:                             

City:          State:         Zip:  

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 Medical Corps puts pictures of the class on our web site. If the occasion
arises, may we post do this 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 $150 deposit check to:

Medical Corps 410 Front Street # 3 Marietta, Ohio 45750