Medical Billing Enrollment Application

Apply for the Medical Billing course at Hawaii Healthcare School. Classes run throughout the year via live Zoom.

Personal Information

Please provide your legal name exactly as it should appear on your certificate.

Last Name *

First Name *

Middle Name

Phone / Contact # *

Email Address *

Street Address *

City *

State *

ZIP Code *

Emergency Contact

Provide someone we can reach in an emergency.

Contact Name *

Relationship *

Phone Number *

Course Information

Schedule: Tue/Thu/Fri • 5:30pm – 9:30pm • Online (Zoom)
New sessions run throughout the year via live Zoom. Contact us or join the interest list to be notified when upcoming dates are released.

Payment Option *

Deposit — $300 today Remaining $2,100 due before first day of class Pay in Full — $2,400 No balance due — everything paid upfront

Agreement & Signature

Please read the enrollment agreement carefully and sign below.

Agreement is binding: This agreement is binding only when it has been fully completed, signed and dated by the student and authorized representative of the school prior to the time instruction begins.

Changes in the agreement: Any changes in the agreement will not be binding on either the student or the school unless such changes are acknowledged in writing by an authorized representative of the school and by the student. We reserve the right to cancel classes for any reason or postpone classes due to insufficient enrollment. Every effort will be made to notify you of a cancelled class well in advance. If we cancel a class, you will receive a full refund of the class fees paid. Telephone cancellation by the student is not accepted.

Effective date of acceptance: I hereby agree by the conditions set forth herein. I declare I am 18 years or older, a high school graduate, and have no criminal record.

Felony Certification *

Type your full legal name to certify: "I have no history of conviction of any felony, such as theft, abuse, assault, neglect, or drug use."

I have read and agree to all the terms and conditions of enrollment stated above. *

Signature — Type Full Name *

Date

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