School Registration School Name∗ Address∗ Zip∗ City∗ State∗ Phone∗ Fax Email Address∗ Website School Coordinator Contact info: Name∗ Position∗ Email∗ Name Position Email Name Position Email Please Check the following ways your organization would like to test: Online Testing Traditional Pencil and Paper Testing School Course Questionnaire Check any of the following programs/courses that are taught in your school. Clinical Certified Clinical & Administrative Medical Assistant (MA1) Certified Phlebotomy Technician (PH1) Certified EKG Technician (EKG1) Certified Patient Care Technician (PC1) Certified Medical Laboratory Assistant (MLA1) Certified Pharmacy Technician (PT1) Certified Veterinary Assistant (VA1) Certified Medical Scribe (MS1) Certified Insurance Exam Technician (IE1) Certified Allied Health Instructor (AHI1) Administrative Certified Medical Billing & Coding (MBC1) Certified Medical Administrative Assistant (MAA1) Certified Electronic Health Records Specialist (EHR1) If you offer any other course please enter it here. Course Name Add More Other Information: How long has the school been in operation ? Yrs How many training programs are taught per year at this site ? Average number of students per class start at: Approximate total number of students per year: Return this application with a copy of your state education department or post-secondary school approval/license or email copy to admin@medca.us
