Radiation Safety Certification Registration (Live Webinar)

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Live Zoom Webinar from 8am - 6pm PST on the selected date.

Zoom invitations will be sent directly to the students by email.

Registration for each class closes 48 hours before the class date.

Email *

Class Date *

Student First & Last Name *

This is how the name will appear on the certificate. Provided to the student upon completion.

Student Email *

A class invitation link will be sent directly to the student at this address, as well as all class communications. Please inform them of an incoming invitation.

Hospital/ Clinic Name *

Billing Name *

Invoicing will go under this name.

Billing Email *

This is where the invoice will be sent. You will receive an email invoice from Square. Please check the spam folder. Registration for the live webinar is $360 per person. Certification lasts a lifetime with no need for renewal.

Any additional comments

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms