Your browser does not support JavaScript!
This form cannot automatically check that you have submitted all of the required fields without JavaScript.
Please be sure to submit all required fields (marked with stars).

Goodland Regional Medical Center

Goodland Regional Medical Center Class Online Payment Form

Welcome to Goodland Regional Medical Center online payment for educational classes. After enrolling, you may pay for your class here by credit card or online check payment.
For your convenience, please fill out the payment form below. All information will be kept secure and confidential. For more information you may call our business office at
(785) 890-6009, Monday-Friday, 8:30 a.m. to 5 p.m.
* Name
Student enrolled in class
* Billing Address
Address where your credit card or bank statement is mailed.
* City, State, Zip
Please include your city, state and five digit zip code.
  Your E-mail address
Please provide an email address.
* Name of the Class
Please list the name of the class.
* Cardholder First Name
The first name of the account holder as it appears on the credit card.
* Cardholder Last Name
The last name of the account holder as it appears on the credit card.
* Amount of Payment
Format: 45.67 (Include decimal and cents. Do not use a dollar sign.)		 $
* Card Number
* Expiration Date
* Card Code Verification Number
The three digit number on the back of your card. (Four digit code on the front of American Express.)
* Billing Postal or Street Address
* Billing City
* Billing State
* Billing Zip Code
5 digit zip code