Student Registration Form

Fill out the form carefully for registration
Please do not complete this application form if you are not 100% sure about joining the next available class. We do secure your seat when you complete our online application. After you complete your online application, please call the academy to set an appointment to make payment for your service. We do offer Payment Plans for all services! ALL BOOKS ARE INCLUDED IN PRICE OF SERVICE!!!
Please Select Course (Select Times At Bottom of App)*

OCT 24, 2023 10-WEEK Phlebotomy & IV Certification - (Tues & Thurs 9am or 5:30pm) $1,650.00OCT 24, 2023 8-WEEK Phlebotomy Certification - (Tues. & Thurs - 9am or 5:30pm) $1,250.004 DAY IV CERTIFICATION - Oct. 10&12 and Oct. 17&19 $400.004 DAY IV CERTIFICATION - Nov. 13&15 and Nov. 21&23 $400.00JAN 8, 2024 - 16 Week Pharmacy Technician - (ExCPT Exam Only) $2,600.00
Name*

First NameLast Name
Birth Date

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student E-mail*
Mobile Number*

Area CodePhone Number
Phone Number

Area CodePhone Number
Job Information
Are you currently employed?*

YESNO (Please leave job info blank)
Company Name
Title
What position do you hold
Supervisor Name

First NameLast Name
Department
What area do you work
Start Date
Work Phone
Emergency Contact Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Relationship
Education History
Name and Location of School*
Major / Courses Studied*
If high school education only type(REQUIRED)
Year attended / Graduated*
Diploma / Degree Type*
References

Relatives are accepted
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Years Known
Background Information
Have you ever been convicted of, placed on probation for, or received Deferred

Adjudication for a felony or misdemeanor, or are you currently awaiting trial for, on

Probation or Deferred Adjudication for, a Felony or Misdemeanor?
*

YesNo
If yes, please identify the crime for which you were convicted or given deferred adjudication, the date of the conviction / deferred adjudication and the location of the court. Convictions will not necessarily disqualify an applicant. All facts and circumstances will be considered.
Applicants can not currently be on probation when seeking employment
Authorization

I understand that the Program will verify all data provided in my application. I authorizesuch investigation and the giving and receiving of any information requested by theprogram. I release from liability any person giving or receiving such information.I understand this entire application must be completed. Omission of information orfailure to submit required documents may invalidate this application from furtherconsideration for enrollment, or if enrolled, may subject me to immediate dismissal.I understand that this application is not a contract between me and Pharmacy & Phlebotomy Technical Academy and that there is no real or implied warranty.
By typing your name you agree/authorize*

First NameLast Name
Date*

MonthDayYear
Date
Payment Installment Agreement

I, certify that this is an agreement between myself and Pharmacy & Phlebotomy Technical Academy. I agree to make timely payments for my education as it states below. Should I fail to make payment on or before the specified dates, I understand that I will not be able to attend class if I do not have my Bi-Weekly payment. I understand that all academy time off is factored in my tuition. A late fee of $25 will be applied after a 3 day grace period or dropped from the course. If both tuition and late fee is not paid on or before the grace period my installment account will be put in default status and unable to attend class. Should I miss more than three days of any course, my account will be put in default status and I will be dropped from course. I understand that I will not be able to re-enter class and forfeit my rights for refund. I agree to pay a $25.00 FEE on each returned check that is written for tuition and will not return to the academy until my full payment is received in CASH OR MONEY ORDER. I understand that I will be dropped/dismiss from the academy if I make payment with a NSF/HOT CHECK and reported to the Jefferson County Hot Check Division if not paid! NO REFUNDS ON DOWN PAYMENTS/TUITON ARE ALLOWED! THE ACADEMY WILL DROP THE STUDENT FROM THE PROGRAM FOR NON PAYMENT OF TUITION AT THE ACADEMY’S DISCRETION!!! I do understand that a 15 minute grace time is allowed for tardiness for all courses and doors to the facility/classroom will be locked 15 minutes after scheduled class times. The academy/instructor has the authority to drop any student from the course to which they feel has a conflict of interest or do not comply with disciplinary actions whether written/verbal without refund. All uniform patches must be sewn or ironed on scrubs prior to attending class!(NO EXCEPTIONS).NO CELL PHONES ARE PERMITTED OUT ON TABLES WHILE EXAM/QUIZZES OR NOTE TAKING IS IN PROGRESS.(NO EXCEPTIONS) NO PICTURES CAN BE TAKEN OF ANY COURSE MATERIALS(EXAMS/QUIZZES), NO EXCEPTIONS. IF STUDENT IS CAUGHT TAKING PICTURES OF COURSE MATERIAL OR CELL PHONE OUT WHILE EXAM/QUIZZES OR NOTE TAKING IS IN PROGRESS THEY WILL BE DROPPED FROM COURSE IMMEDIATELY WITH NO REFUND AWARDED! IF FOR ANY REASON YOU ARE CAUGHT CHEATING ON ANY TEST MATERIAL YOU WILL BE DISMISSED AND DROPPED FROM THE COURSE IMMEDIATELY! ALL STUDENTS ARE REQUIRED TO MAINTAIN A 70% GRADE AVERAGE ON 3 CONSECUTIVE EXAMS/QUIZZES TO CONTINUE IN ALL COURSES OFFERED, IF THIS AVERAGE IS NOT MAINTAINED AT ANY GIVEN TIME THE STUDENT WILL BE DROPPED FROM THE COURSE WITH NO REFUNDS ALLOWED AT THE INSTRUCTORS CHOOSING!
By typing your name you agree/authorize*

First NameLast Name
Date*

MonthDayYear
Date
Waiver and Assumption of Risk

I, voluntarily sign this Waiver and Assumption of Risk in favor of the owners, __Jessie Mayes______________ for the opportunity to use the owner’s facilities and/or the opportunity to receive instruction from the owners employees and/or to engage in the activities sponsored by the owners as follows: I understand that there are certain risks and dangers associated with the activity and use of the facilities and that these risks have been fully explained to me. I fully understand the dangers involved. I fully assume the risks involved as acceptable to me and I agree to use my best judgment in undertaking these activities and follow all safety instructions. I waive and release the owners from any claim for personal injury, property damage, or death that may arise from my use of the facilities or from my participation in the activities or instruction. I am a competent adult and I assume these risks of my own free will.
By typing your name you agree/authorize*

First NameLast Name
Date*

MonthDayYear
Date
PHLEBOTOMY TRAINING COURSE Please choose which class option you will attend

Mornings 9am - 12pmEvenings 5:30pm - 8pm
PHARMACY TECHNICIAN TRAINING COURSE Please choose which class option you will attend

Morning 9am - 1pm (Monday, Wednesday, Friday)Evening 5:30pm - 9pm (Monday, Wednesday, Friday)
4 DAY IV CERTIFICATION Please choose which class option you will attend

Morning 9am - 11am (Tuesday & Thursday)Evening 6pm - 8pm (Tuesday & Thursday)
After you complete your online application please call the academy and make an appointment to pay by check, cash or money order. We do not accept credit card payments at this time.

ACCEPTABLE PAYMENTS: CHECK(NO New Accts. Accepted), MONEY ORDER, CASH, CASH APP or VENMO...

CASH APP PAYMENT: $mrjessieppta

VENMO APP PAYMENT: $mrjessiePPTA
Additional Comments
Should be Empty:

Student Registration Form

Job Information

Emergency Contact Information

Education History

References

Background Information

Authorization

Payment Installment Agreement

Waiver and Assumption of Risk