Cedar Rapids – JULY Night Class $400

Class Details

Wednesday, July 29 - Friday, August 7

Class Times

July 29-Aug. 7th(10 days!)
Everyday 5:30-8:30pm
Drives completed by Aug. 7th

Class Location

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Class Registration Form

Spaces

Student First Name *

Student Last Name *

Student Middle Name

Student Preferred Name

Student Date of Birth (MM/DD/YYYY) *

Student Street Address *

City/Town *

State *

Zip Code *

Student DL No./Permit # (Not required)

Student Cell Number

Name of School *

Primary Email Address *

Parent Cell Number *

Parent First and Last Name *

Work or Home Number

Primary Doctor *

Primary Doctor Phone Number *

Preferred Hospital

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