Enrollment Form

First Name*

Last Name*

Email*

Date Of Birth*

Social Security Number

Phone*

Address*

City*

State*

ZIP / Postal Code*

Upload copy of Birth Certificate or GED

Emergency Contact

Contact Name*

Contact Phone Number*

Program Information:

Choose Program:

Phlebotomy Program

Medical Assistant Program

Start Date

Choose A Location:

2418 E York Street Philadelphia, PA 19125

4300 Paces Ferry Rd - Suite 500 Atlanta, GA 30339

Program Enrollment Requirements:

The above named individual is required to complete 50 hours of practical instruction in Phlebotomy or Medical Assistant
For a student to be eligible to take the final certification exam they must meet the following prerequisities:

Successfully completion of the phlebotomy training program
Successful completion of 30 venipunctures (blood draws)
Successful completion of 10 capillary sticks (finger sticks)
Possess a high school diploma or equivalent
Be 18 years of age or older

Program Enrollment

Program Enrollment - Review & Sign

Program Enrollment

I acknowledge the following:
For a student to be eligible to take the final certification exam they must meet the following prerequisities:

Successfully completion of the phlebotomy training program
Successful completion of 30 venipunctures (blood draws)
Successful completion of 10 capillary sticks (finger sticks)
Possess a high school diploma or equivalent
Be 18 years of age or older

Non-refundable deposit of $350.00 is required with payment plan options. The full program fee payment of $1197.00 is required before taking final exam