Q-MAP REGISTRATION

 
Please complete the form below to register for the Q-Map Class. We will review your registration and get back to you at our earliest convenience. Thank you.

Student Last Name (required)

Student First Name (required)

Birth Date

Address

Address 2

City

State

Zip/Postal Code

County

Telephone (required)

CellHomeWork/Office

Alternative Telephone

CellHomeWork/Office

Your Email (required)

Are you currently Q-Map certified? (required)
YesNo

If yes, when does your certification expire?

Have you EVER had a Q-Map certification that expired? (required)
YesNo

If yes, when did it expire expire?

What is the highest level of education completed? (required)

If no education, do you have basic math skills (addition, subtraction, multiplication, division)?
YesNo

Current Employer

Current Employer Telephone

CellHomeWork/Office

Do you speak and understand English?
YesNo

Do you have access to a computer?
YesNo

By typing your name below (required), you acknowledge that you have completed this application to the best of your ability and that the information you have provided on this application is correct and truthful. You are also acknowledging that "I understand the following that all registration forms and payment must be received no later than seven (7) day prior to date of class starting; all payments must be in the form of a money order, electronic payment using PayPal or Cash.me or business check payable to the Shared Touch in the amount of $115.00 (testing only) or $140.00 (3-hour class review and testing). I will be notified via telephone or email to confirm that registration form was received.

I, also understand that if I decided to attend class and cancel after class has started NO REFUND will be given.
If the instructor has to cancel class I will be notified via e-mail and by telephone. The class will be rescheduled within thirty (30) days. If I choose not to attend the rescheduled class, a refund will be issued within three (3) business day of the date of the cancelation.

Type Name Below to Agree to the Above (required)