FEDEN Healthcare Education Institute A Division of FEDEN Enterprise Inc.

10556 South US Highway 1, Port St Lucie, FL, 34952

Phone: (772) 343-1650 Fax: (772) 343-1652

E-mail: fedengroup@yahoo.com Website: www.fedengroup.com

TRAINING REGISTRATION FORM

Name: ________________________________________________________ Date: __________

Address: ___________________________________________________________________

City/State/Zip:___________________________________________________________________

Cell Phone: _________________________________ Work Phone:__________________________

Telephone: __________________________________ Fax: ________________________________

E-mail address: ___________________________________________________________________

Organization (if any): ______________________________________________________________

Contact person (if any): ____________________________________________________________

Course Name: ______________________________________ Course Date: __________________

Total amount enclosed: $ _______________________________(Balance) $___________________

How were you referred to FEDEN Organization:

£ Mail notice £ Website £ Flyer £ Organization/Employer £ Friend £ Other _____________

Registration Deadline: Payment and registration form must be received five (5) days prior to course date to guarantee your seating. Limited Seating available. CLASS WALK-INS NOT RECOMMENDED (except on Mondays for CPR).

Payment Method
Cash Check or Money Order Paypal (fedengroup@yahoo.com) Zelle (7722123095) _Cash App ($feden)
Credit/Debit Card (There is an additional 4% bank card fee and complete information below or call) *** All returned checks will be charged a $45.00 service fee *
Name of Cardholder _________________ Signature of Cardholder _
Billing Address for Credit Card ________________________
Acct. Number _ Type: _VS _MC _Discover ?Other
Verification code (on back of card) Expiration Date Amount: ________(plus 4% card fee)

NOTE: Make check(s) or money order payable to: FEDEN Healthcare Education Institute

FOR REGISTRATION & MAILING: Please mail the completed registration form and payment to:

10556 South US Highway 1, Port St Lucie, FL 34952

PLEASE NOTE: No fees will be refunded if this office does not receive written notice of cancellation. Three (3) business days prior to the start of training. Fees paid for training missed may not be applied toward any future training without prior notification & approval. All refunds are to be processed within 14 days.
A $45.00 nonrefundable processing fee will be applied to all Refund/Cancellation/CNA testing fee and an additional $5 applied to all credit card refund.

FEDEN Healthcare Education Institute reserves the right to refuse to provide training and/or professional services to non-compliant participants.

All training may be subject to date change or cancellation.

(copy of this form is accepted)