School Registration Form HVAC Fundamentals: Hands-On Training with CFC & State Licensing

Course Registration

HVAC Fundamentals: Hands-On Training with CFC & State Licensing
Welcome to Southern Maryland HVAC Academy
Additional documents for registration

Bring the following documentation with you the 1st day of class.

• Copy of Drivers License
• Current Proofs of Residence (ex. Electric bill, Water bill, gas bill, ETC )
Receipt Number
Student Information
Name*

First NameMiddle NameLast Name
Birth Date *

MonthDayYear
Email Address*
Phone Number*
Please enter a valid phone number.
Last School you Attended
How long to you attend
Have you previously received any HVAC Training?

YesNo
If yes, how many hours of training?
Current Residence Information
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Primary Residence Information (if different from above)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact 1
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Emergency Contact 2
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Physician and Medical Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Allergies and or Chronic Health Condition. Please Type none if this does not apply to you.*

Previous School
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency below. Thank you.
Should be Empty:

Emergency Contact 1