Upcoming Classes Don't Miss Out! Spots Are Filling Up Quickly! Name(Required) First Last Email(Required) Phone(Required)How Did You Hear About UsReferred From a FriendOnline SearchDental OfficeMedical OfficeFunding SourceProgram(s) You Are Applying For(Required) Dental Assisting Dental Administrative Medical Assisting STNA CPR How many programs are you enrolling in?(Required)Please enter a number from 1 to 5.Dental Assisting Registration Information State(Required)OhioPennsylvaniaLocation(Required)ColerainWest ChesterLocation(Required)BensalemSession(Required)SpringSummerFallWinterLocation(Required)FlorenceLearning Style(Required)HybridDental Administrative Registration Information State(Required)OhioLocation(Required)West ChesterSession(Required)SpringSummerFallWinterLearning Style(Required)HybridMedical Assisting Registration Information State(Required)OhioArizonaLocation(Required)West ChesterLocation(Required)Online OnlySession(Required)SpringSummerFallWinterLearning Style(Required)HybridState(Required)OhioLocation(Required)West ChesterColerainSession(Required)Saturday, August 17Saturday November 16Learning Style(Required)In PersonPayment Option for Class 1(Required)Option 1 - Pay In Full By First Day of ClassOption 2 - Biweekly PaymentsOption 3 - $1,000 Down, Bi Weekly PaymentsPayment Option For Class 2(Required)Option 1 - Pay In Full By First Day of ClassOption 2 - Biweekly PaymentsOption 3 - $1,000 Down, Bi Weekly PaymentsDental Assisting Registration Fee(Required) Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feeDental Administrative Registration Fee(Required) Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feeMedical Assisting Registration Fee(Required) Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feeMedical Assisting Registration Fee(Required) Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feeCPR Registration Fee(Required) Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $99 fee + 2.5% processing fee$1,000 down due with the registration form for Class 1(Required) Price: $1,000 down due with the registration form for Class 1(Required) Price: $1,000 down due with the registration form for Class 2(Required) Price: Registration Fee(Required) Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feeRegistration Fee(Required) Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feeRegistration Fee(Required) Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feeRegistration Fee(Required) Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feeRegistration Fee(Required) Price: ** Registration fee is deducted from your total tuition and is non-refundable. ** $125 fee + 2.5% processing feeTotal Paytrace Card Number Month010203040506070809101112 Expiration Month Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Year Security Code Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Consent(Required) By checking this box, you are agreeing to the authorization. I hereby authorize The Union Centre Institute to initiate ACH debits to my bank account. I understand I may revoke this authorization by calling Katie Dougherty @ 513-855-5100 or emailing Katie@unioncentreinstitute.com within 3 business days prior to the authorized processing date. All transactions and refunds are handled on a case-by-case basis. Please contact Union Centre Institute if you have questions or concerns regarding any transaction or refund.
