Student Last Name (required)
Student First Name (required)
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) High SchoolTrade SchoolSome CollegeCollege
If no education, do you have basic math skills (addition, subtraction, multiplication, division)? YesNo
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)