Student Information Student Name (First and Last) Phone Number Email Address City State —ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Last 4 Digits of SSN Were you referred to us by a former student? YesNo Who referred you? (Please provide their first and last name) Course Option Choose Which Location You Wish to Attend: MariettaBuckhead Choose a Class Day and Time —Friday 8:30AM – 5:00PMSaturday 8:30AM – 5:00PM Choose a Class Day and Time —Saturday 8:30AM – 5:00PMWed – Thurs 6:00PM – 9:00PM Scrub Sizing Size XXS XS S M L XL Numeric 0-2 2-4 6-8 10-12 14-16 18-20 Bust 33-35 35-36 37-39 40-43 44-47 48-50 Waist 24-26 26-27 28-31 32-34 35-38 39-41 Hip 35-37 37-38 39-41 42-45 46-48 49-52 So that we may order the correct scrub uniform for you, WE NEED TO KNOW YOUR SIZE. Selection XXSXSSMLXL Expected Payment Method —Credit CardCareCredit®Specialized Payment Plan Payment Confirmation I understand my application form will not be processed and accepted without receiving a form of payment. Note: You must choose one of the payment options (below) in order to register.