50 Lydia Lane

South Portland, ME 04106

Phone: (207) 523-5019 Fax: (207) 874-8079

Registration Form

Please do a save as and type in this form for legibility reasons. Registration closes two weeks prior to the class being offered. Please note: It is up to the instructors’ discretion to allow late arrivals to join the class. Please contact Georgia stone at 207-553-5947 for class availability prior to sending the registration form.

Name of Participant:
Email Address:
Home Mailing Address:
Telephone:

Employer Agency:
Title
Agency Mailing Address:
Agency Telephone:
Agency Fax:

Who will be paying for this training? Participant	Employer

Credit Card Information:	Visa	MasterCard

Name as it appears on card:
Card Number:
Expiration Date:

If accommodations are necessary for you to attend, please specify:

Please Check Course For Enrollment	Course Date	Course Time
Example:	4/1/16	9:00 am
Care of the Diabetic with Epi Pen Auto-Injector Video ($45)
*CRMA 40 Hours ($425)
*CRMA Recertification ($125)
CRMA Refresher for Recertification ($25)
MANDT Full (Non-Restraint) ($170)
MANDT Recertification (Non-Restraint) (Cost $85)
MHSS ($275)
Other: Please List

*Please note that in order to complete CRMA the med pass will need to be completed by your employer.

Signature:	Date:

Thank you for choosing The Opportunity Alliance for your training needs. Please electronically sign and email the form to Patty.Mann@opportunityalliance.org or fax to 207-874-8079. Please note that you are not registered for a course until a confirmation email is returned.