Self-Paced Radiation Safety Registration 
This registration form will provide access to the Self-Paced Online Radiation Safety Certification Course to be completed at their convenience.  Registrations after 10/21 will be processed on 10/26.  Thank you for your patience.
Sign in to Google to save your progress. Learn more
Email *
Student's First & Last Name *
This is how the name will appear on the certificate.  Provided to student in the Mighty Network upon completion.
Student's Email Address *
This is where the course access invitation will be sent.  An email will come from Mighty Networks.  Please have them keep an eye out for this invitation as it may go to the spam folder.
Hospital/ Clinic Name *
Billing Name *
This is who the invoice will be under.  The registration fee for the self-paced course is $367 per registrant.  Certification lasts a lifetime.  The student gets lifetime access to the content.  
Billing Email Contact *
This is where the invoice will be sent.  You will receive an email invoice from Square.  Please check the spam folder.
Additional Comments
If you have any further comments or questions, feel free to share them here.  Thanks!
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy