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woman survival registration page

Woman Survival Academy does not receive donations or funding for this free TUITION program.

Date / Time *

Date

Time

Student Details

Name *

First

Last

Date of Birth *

Sex *

Email *

Phone *

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Current or Previous Occupation *

Marital Status *

What Program are you applying for *

Why are you applying for this program *

Have you ever taking any training with Woman Survival *

Did you watch the four videos on this page before filling out this application *

Were you referred by a case manager *

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name *

First

Last

Contact Number *

Relation to you *

Education and employment details

Where are you currently employed *

List the name of your employer *

Have you ever taken and healthcare or medical training courses? *

If you answered yes above. Please list all of the trainings you have taken

Please list all certificates, certifications, and license you currently have or have had in the past *

If you have a case manager paying for this program or paying for your supplies for the tuition free program please tell us about the program

Name of program *

Case Manager Name *

Woman Survival Refund and Cancellation Policy

( Registration fee is non-refundable) What is the Refund Policy if you’re not accepted into the Program? – If the student is not accepted into the training program, all monies paid by the student shall be refunded. Refunds for books, supplies and consumable fees shall also be refunded in 10 business days in accordance with Woman Survival handbook Payment/Cancellation/Refund Policy Refunds & Transfers All deposits and balances for training programs are non-refundable and non-transferable. However, we understand that emergencies happen, so if you are unable to attend a training that you have paid-in-full, and you cancel with more than fifteen (15) days notice before a scheduled training, you may request to credit or transfer 50% of total training fee to another class within 12-months of request. If you cancel within fifteen (15) days of a scheduled training, you will forfeit your entire tuition. It is recommended that you purchase travel insurance, which can protect you by refunding monies paid if you need to cancel your trip due to an emergency. Travel insurance is very affordable and can protect you in other ways as well. Training Changes or Cancellations Woman Survival reserves the right to cancel any training, limit class size, change class times or substitute instructors for those listed in the schedule. If a training is cancelled, students may choose to receive a full refund or may transfer – with no fee – to another class . If Woman Survival cancels for any reason, all payments can be refunded. Participation Waiver Registrant acknowledges that registration and participation is voluntary, and that by registering for this class that he/she is solely responsible for any loss, damage or injury, including death, that may be sustained on the premises or any location where any class is being conducted. *

I clearly understand Woman Survival refund and cancellation policy *

Yes

I clearly understand that I must upload my state issued photo ID before submitting this enrollment agreement *

Yes

I clearly understand that the credit card I use to enroll in this program MUST be in my name or the registration will be voided. *

Yes

Name *

First

Last

How Did You Hear About Us? *

Internet/Search Engine
Friend Referral
Social Media
Referral
TV/Radio
Third-Party Review
Other
Case Manager

If other, please specify *

Please explain in a paragraph why you feel you are a candidate for this class? *

Upload a copy of your state issued valid photo ID *

Click or drag files to this area to upload. You can upload up to 100 files.

Checkbox Items

April 30th Class Medical Assistant Non- RefundableRegistration Fee

Stripe Credit Card *

Powerwd by Woman Survival