Registration | East Valley Nursing

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Registration Form

First name

Middle name

Last name

Date of Birth

Phone

Email

Street

City

Region/State/Province

Postal / Zip code

Gender identification

Last 4 digits of SSN

Preferred schedule

Choose payment plan

High School (if applicable)

High School diploma (if applicable)

Upload File

Upload supported file (Max 15MB)

GED (if applicable)

Upload File

Upload supported file (Max 15MB)

Transcripts

Upload File

Upload supported file (Max 15MB)

click here to download and sign the Enrollment Agreement form

Thanks for submitting!

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