Apply to a Certificate Program

Certificate Program Application

MelroseWakefield Healthcare at Lawrence Memorial/Regis College

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Choose which program you're applying for:*

Computed Tomography (CT)

Magnetic Resonance Imaging (MRI)

Your Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone #*

Primary Email*

Enter Email Confirm Email

Emergency Contact Name

Emergency Contact Phone #

Are you licensed through ARRT, NMTCB, or other nationally-recognized licensing body?*

Yes

How did you hear about this program?*

Co-worker

Current program student or graduate

www.lmregis.org website

Other

Today's Date*

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