Healthcare Service Training Registration

Parent/Guardian's First Name^*

Parent/Guardian's Last Name^*

Parent/Guardian's Email Address^*

Parent/Guardian's Phone Number^*

I, the student, or I/We the parent(s) or legal guardians of assume full responsibility for, and assume payment of all fees and tuition charges due hereunder. By authorizing a registration for the courses on this form, I/We agree to be charged the fee set forth in New York Tech’s online catalogs and nyit.edu. I/We agree to be bound by this registration form and abide by New York Tech’s rules and regulations set forth in New York Tech’s online catalogs and nyit.edu. I/We agree to pay my debt to New York Tech for any amounts due for tuition and fees and other charges. If my charges are not paid when due, I/We agree to pay New York Tech all fees and costs associated with the collection of my delinquent account. In addition to payment of the principal amount due, the additional fees and costs may include collection agency fees constituting 33 to 50 percent of the principal amount due if New York Tech engages a collection agency to collect payment; legal fees of 33.3 percent of the principal amount due if New York Tech engages legal counsel to collect payment; any and all interest on the outstanding balance at the maximum legal rate allowed by law and; any and all other costs associated with collection of the amount due New York Tech. I/We understand my obligation to pay these additional fees and costs associated with collection of my delinquent account. ^*

Street Address^*

City^*

Country^*

State

Postal Code^*

Primary Phone^*

Mobile Phone

Email^*

Are you a veteran?^*

Yes

Do you have a social security number?^*

Yes

Have you received a complete COVID-19 vaccination?^*

Yes

Please enter the characters displayed in the image below.^*

Note: Upon submission, you will receive instructions to fill out and upload an additional PDF form as part of your application. Please carefully review those materials and reach out to healthcaretraining@nyit.edu with any questions.

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