New REGISTRATION FORM - Mishilo Academy

REGISTRATION FORM

Student Information and enrolment status.

Mishilo Academy Inc.
T: 778.697.7456 E:
admin@mishiloacademy.ca

COLLECTION AND USE OF PERSONAL INFORMATION

Mishilo Academy Inc will only collect and use your personal information for the sole purpose of enrollment into the program. If you have any questions pertaining any of the questions, please contact admissions at the information provided above.

PERSONAL INFORMATION

Name *

First

Middle

Last

Birth Date *

Preferred First Name

Gender *

CONTACT INFORMATION

Home Mailing Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Home Number

Mobile Phone Number *

please enter 00000 to fill the second required field for telephone number

Email Address *

PROGRAM SELECTION (select as required)

Dental Management Program

Full Program - $ 1200.00 + Tax

Dental Reception Certificate Program

Full Program (Level 1 &2) tax incl. - $ 2,200.00
Level 1- tax incl. - $ 1,100.00
Level 2- tax incl - $ 1,100.00

Self-paced
Scheduled Classes (confirm the schedule)

Dental Sterilization Program

Full Program - $ 880.00 + Tax

Existing Dental Reception enhancement program

Total Amount

$ 0.00

PAYMENT- Full payment is required at the time of registration. (Select your method of payment) *

Credit card
E-transfer (this option is only available for Canadian students)