MEDPREP Registration Form

STEP #2

Please note: All information asked is State Required.

Start Date:.........
First Name:........
Last Name:........
Gender:..............
Birth Date:.........	//

Phone:................	() -
Address:.............
City:....................
State:..................
Zip Code:...........
Email:.................

Education:..........
Race:..................

Hispanic:............

Disability:.............

YES NO

Have you been registered as a nursing assistant in Washington State before?........................

YES NO

How were you referred to this school?................

IN CASE OF EMERGENCY

Name:.. Phone:..() -

I am in agreement to the (5) 8-hour facility clinical days.
I have a scheduling conflict and need to discuss clinical hours.

By submitting this link you hereby acknowledge the above is filled out truthfully to the best of your knowledge, and you are responsible for any false information given above.

Note: All fields are required to be filled in, to continue to the next step!

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