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Allied Health - Piedmont CC
Select Class*  
Nurse Aide I, $188
Nurse Aide II, $188
Nurse Aide Refresher, $125
Medication Tech, $70
Medication Aide, $70
Cardiovascular Tech/Monitor, $188
Healthcare Provider CPR, $50

Above cost is only for class registration fees. The cost of textbooks, state board exams, and supplies are not included.
Class Start Date*  
Class End Date*  
Section Number  
Class Location*  
E-Mail
Important: Enter a valid e-mail address. All correspondence will be sent to this address.
E-Mail:*  
Registrant Information
First Name:*  
Middle Initial:  
Last Name:*  
Address Line 1:*  
Address Line 2:  
City:*  
State:*  
County (NC residents only)  
Zip Code:*  
Home Phone:*  
Work Phone:  
Cell Phone:  
Sex*  
Male Female 

Date of Birth*  
  
  
SSN*  
Colleges and Universities are asked by many, including the federal government, accrediting associations, college guides, newspapers, and your own college/university communities, to describe the racial ethnic backgrounds of our students and employees. In order to respond to these requests, we ask you to answer the following two questions:
Do you consider yourself to be Hispanic/Latino?*  
Yes No 

Ethnic Origin:*  
Educational Experience
Highest Educational Level Completed*  
Employment Status
Employment Status:*  
Electronic Signature
I understand that having any unpaid balances wtih Piedmont Community College may affect my enrollment in this class.
Signature:*  
Enter first & last name
Date*  
Photography & Quote Release: I hereby authorize Piedmont Community College to use my image and/or quotes for any use the College deems appropriate in the promotion and marketing of PCC. I fully discharge PCC from any and all claims, monetary or otherwise, arising out of the image or quote.
Signature:  
Optional, sign if authorized
Date:  
Credit/Debit Card Payment Information
*****Please note, your card will not be charged immediately upon submission.*****
Once received, you will be registered for your class and payment will be sent to our business office for manual entry. You will only be contacted if there is a problem.

Name on Card*  
Is billing address the same as address above?*  
Yes No 

Billing Address  
Enter billing address if different from registration address.
City  
State  
Zip Code  
Credit Card Number*  
Card Brand*  
Security Code*  
Expiration Date*  
Amount to be Charged*  
PCC offers an optional student insurance fee of $1.25 per semester. Please add $1.25 to your registration fee if you elect to pay for this insurance.
Electronic Signature for Credit Card Charge
I hereby authorize Piedmont Community College to charge my credit card for the amount listed above.
Signature*  
Date*  
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