Program Payment Form

🧑‍🎓 Student Information

Full Name: _______________________________________
Phone Number: ____________________________________
Email Address: ____________________________________

Program Enrolled In (check all that apply):
☐ CNA  ☐ Medication Aide  ☐ CPR  ☐ EKG
☐ Phlebotomy  ☐ Medical Assistant  ☐ CARES Courses
☐ Other: ___________________________________________

💰 Payment Options (Select One):

✔ We accept scholarships, grants, and flexible payment plans.
❌ We do NOT accept FAFSA or federal financial aid.

☐ Zelle
Send to: [email protected]
Confirmation #: ___________________

☐ Cash App
Send to: $mps2018
Cash App Name: ___________________
Transaction ID: ___________________

☐ PayPal
Send to: [email protected]
Transaction ID: ___________________
☐ Paid in Full  ☐ Payment Plan (attach agreement)

☐ Cash (in-person only)
Received By: _______________________
Date: _____________  Amount: $__________

☐ Scholarship/Grant
Name of Scholarship/Grant: __________________________
Approved Amount: $__________

🗓️ Enrollment Date: ____ / ____ / ______

📝 Student Signature: ___________________________