Today's DateAbout MeName(Required) First Middle Initial Last Email(Required) Cell Phone Number(Required)Gender(Required)-FemaleMaleOtherRace(Required) American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Prefer Not to Respond Prefer to Self-Describe Highest Level of Education(Required)-10th grade11th gradeHigh School diplomaGEDSome CollegeVoTech ProgramAssociates DegreeBachelor DegreeMaster's DegreeUpload your transcript or diplomaMax. file size: 10 MB. Veteran or Military Service Member?(Required) Yes No Prefer not to disclose Address(Required)City(Required)State(Required)-AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code(Required)SSN(Required)Date of Birth(Required)YYYY-MM-DDMy EnrollmentState(Required)Please select your stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingClass Start Date(Required)YYYY-MM-DDProgram Name(Required) Phlebotomy IV Therapy Prior Medical Training/Employment(Required)Upload your license / credential documentMax. file size: 10 MB. Payment Method(Required) Cash Check Credit Card Other Emergency InformationPerson to contact in case of emergency(Required)Emergency contact phone number(Required)Insurance Carrier Information (if any)In case of emergency, I authorize Northwest Phlebotomy School to contact emergency medical staff on my behalf in order to obtain medical care.(Required)I understand I must show up to class lucid, and mentally and physically rested and prepared. I understand that if the instructor feels I am not prepared I can be questioned, and if necessary dismissed from that session with the instruction to be prepared for the next session. Students, who are under the influence of alcohol, elicit drugs, prescription drugs or any other mind or body-altering substances cannot participate in class. Student Initial:(Required)I understand that disruptive behavior, vulgar language or inappropriate attire will not be tolerated during class. If after a warning from an instructor or other NWPS staff member the offense continues I may be asked to leave class with out the possible option to return. In this case no refunds will be given. *Scrubs are the preferred attire but are not required. Student Initial:(Required)I understand the risks associated with drawing blood, contracting diseases and am aware that phlebotomy procedures in class will be performed on fellow students, volunteers and staff at Northwest Phlebotomy School. I also understand that any injury sustained to me or the person I am performing phlebotomy on is solely my responsibility and will hold Northwest Phlebotomy School harmless. Student Initial:(Required)I understand that Northwest Phlebotomy School does not offer job placement. However, employment advisement is available as well as an in class discussion on how to obtain and where to look for employment. Student Initial:(Required)I understand that attendance is mandatory to successfully pass this course. Make up class time will be available by contacting Northwest Phlebotomy School only. I understand that I will not be able to schedule or attend make up classes once my registered class has concluded until my tuition is paid in full as explained under General Information on page 2 of this Registration/Enrollment Agreement. Student Initial:(Required)I understand that I must confirm and check the spelling/format of my name and that how my name appears here is EXACTLY how it will appear on my certificate. I also understand that there is a $15 Fee for Certificate Reprints as explained under Payment/Certificate/Exam Information on Page 2 of this Registration/Enrollment Agreement. Student Initial:(Required)I understand that if I cannot complete the course I originally registered for, before I can be reassigned to another class I must have all tuition paid in full. I also understand that if I need to be reassigned to a class for any reason I must contact NWPS to do so. Student Initial:(Required)I understand the Northwest Phlebotomy School Refund Policy and am aware that all requests to withdraw from the program must be done in writing as explained under General Information on Page 2 of this Registration/Enrollment Agreement. Student Initial:(Required)I understand that I will not be able to graduate or obtain my certification until I have completed the course and paid ALL tuition in full as explained under Payment/Certificate Information on page 2 of this Registration/Enrollment Agreement. Student Initial:(Required)I understand that in order to sit for the National Exam, I must have ALL tuition paid in full. Student Initial:(Required)I understand that by signing this agreement, I will receive an exact signed copy of the agreement. Student Initial:(Required)REGISTRATION/ENROLLMENT AGREEMENT I have read and understand this Registration/Enrollment Agreement and agree with the terms set forth therein. By signing below, the student agrees to pay Northwest Phlebotomy School the total stated tuition & fees. The school agrees to provide the occupational training in accordance with the provisions of the school's current 2025 Catalog. Payment of all monies due shall be a condition of continuing enrollment. Upon satisfactory completion of all academic and skill requirements and when all financial obligations to the school have been met the school will award the Phlebotomy Program Certificate to the student. The student and school understand that this Enrollment Agreement, WHICH INCLUDES THE REFUND POLICY may not be amended except in writing and signed by both parties. By signing below, the student also confirms that they have received and read the current Northwest Phlebotomy School Course Catalog. This agreement in not binding until signed by both the student and the Authorized representative of the school.I agree to the Agreement.(Required)Date(Required)YYYY-MM-DD