Senior Care Course Application


Order online or print this form and send it to:

Kelynco
498 East Golden Pheasant Drive
Draper, UT 84020

Or FAX it to: (801) 553-9931

Personal Information  
Company:
Credentials:
First Name:
Last Name:
Preferred Mailing Address 1:
Address 2:
City:
State:
Zip Code:
E-Mail Address:
Phone (day):
Phone (evenings):
Course Information  

Select one of the options below:

$2,500.00 - Advanced Early Bird Registration, paid ninety (90) days prior to the course
  
$2,600.00 - Early Bird Registration, paid sixty (60) days prior to the course
  
$2,700.00 - Standard Registration paid thirty (30) days prior to the course

  Cancellation Fee:  $300

Cancellation Policy
 There are no refunds 20 days prior to the course. In case of injury or illness, The MSA course may be transferred to another course at a later date. Kelynco reserves the right to cancel the course based on low registration or other unforeseen circumstances and will either provide a full refund or change the course date. 

Course Date:
Nursing License Number
Nursing Organization:
How did you Hear about the MSA Course?
Education Information  
College:
Degree:
Year of Graduation:
Nursing Experience:
Other Nursing Experience
By clicking continue, I agree to submit my information and have my credit card charged and I agree to the cancellation policy.

Click [Continue] to be transfered to our secure page where you can enter your credit card information.