Oregon Medical Training Application

Enrollment Agreement

If you have any questions, you may contact us at (541) 343-3100 during business hours or by email at jailac@orphleb.com. We do not accept unfinished applications.

Program	Phlebotomy	Phlebotomy	EKG	Pharmacy
CRN	E090122	B090122	EG090722	EP090122
Term	Fall	Fall	Fall	Fall
Year	2022	2022	2022	2022
Location	Springfield	Bend	Springfield	Springfield
Instructor	Stinchcomb	Cerna	Rice	DePaule
Type	On campus	On campus	Hybrid	On campus
Hours	90 hours	90 hours	54 hours	120 hours
Date	09/01 - 11/29	09/01 - 11/29	09/07 - 11/23	09/01 - 12/13
Days	M-T, Th	M-T, Th	W	M-T, Th
Time	6 - 9 PM	6 - 9 PM	8:30 - 1 PM	8 - 11 AM

Read the requirements and the fill in the information needed below:

a) All information must be completed fully; if a student does not fill in the necessary information, the school has the right to reject the application

b) Do not use a school email address; use only a personal email address

c) If a student refuses to release his or her Social Security Number, the school may assign an alterantive identification number

d) TERMS OF CONTRACT - Student Loan (ORS 345.113)

Student Name *

First Name M.I. Last Name

Program *

Campus Location *

We do not offer EKG or pharmacy programs in Bend, Oregon, at this time.

Are you 18 years of age or older? *

Yes No I will be 18 years old by the commencement date

Date of Birth *

Month Day Year

Gender *

Race *

U.S. Citizen *

Yes No

Oregon Resident *

Yes No

Disability *

Yes No

U.S. Veteran *

Yes No

Primary Email Address *

Do not use a school email address

Cell Number *

Area Code Phone Number

Social Security Number

Do not use hyphens

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

County *

ex. Lane county

Which document did you obtain? *

U.S. high school diploma International diploma General Educational Development Test (GED) I did not obtain any diploma or any GED equivalency

What year did you graduate? *

What high school did you graduate from? *

What is your high school code? Search: https://nces.ed.gov/ccd/schoolsearch/ *

If you obtained a GED certificate, insert "N/A"

Upload Files

Drag, drop and submit copies of your identification documents. You may use alternatives after seeking the office's approval by calling (541) 343-3100 during business hours. Applicants that do not submit the required identification documents will not be accepted in the program.

Required

Optional

✔ Driver's license

✔ High school diploma

✔ Birth certificate

✔ Passport

✔ State issue ID card

✔ High school transcript

✔ GED certificate

Driver's License *

High School Diploma *

Payment Plan Terms of Installment: If a payment is not received within 5 days of the due date, a $59.00 late fee will be applied. Thereafter, any unpaid balance will accrue an additional 10% late fee per month

	Phlebotomy	EKG	Pharmacy
Registration Fee	$150.00	$150.00	$150.00
Supply Fee	$100.00	$100.00	$100.00
Set-up Fee (optional)	$25.00	$25.00	$25.00
Tuition	$2,250.00	$1,650.00	$1,250.00

TOTAL COST	$2,500.00	$1,900.00	$1,500.00

A payment plan is required prior to enrollment. If you do not choose a payment plan, you will be selected for Payment Plan 1 by default with no exceptions. *

Payment Plan 1 Payment Plan 2 Payment Plan 3

Payment Plan 1	Pay $250.00 and total program cost upon enrollment
Payment Plan 2	Pay $250.00 upon enrollment and the remaining balance by the conclusion of week one
Payment Plan 3	Pay $250.00 and an additional $25.00 fee that will split your tuition into three monthly payments due the first day of each month (starting with the month the term starts)

Cancellation and Refund Policies (OAR 715-045-0036)

A student may cancel enrollment by giving written notice to the school. Unless the school has discontinued the program of instruction, the student is financially obligated to the school according to the following:

If cancellation occurs within five business days of the date of enrollment, and before the commencement of classes, all monies specific to the enrollment agreement shall be refunded;
If cancellation occurs after five business days of the date of enrollment, and before the commencement of classes, the school may retain only the published registration fee. Such fee shall not exceed 15 percent of the tuition cost, or $150, whichever is less;
If withdrawal or termination occurs after the commencement of classes and before completion of 50 percent of the contracted instruction program, the student shall be charged according to the published class schedule. The student shall be entitled to a pro rata refund of the tuition when the amount paid exceeds the charges owed to the school. In addition to the pro- rated tuition, the school may retain the registration fee, supply fee, $25 withdrawal fee, and other legitimate charges owed by the student.
If withdrawal or termination occurs after the completion of 50 percent or more of the program, the student shall be obligated for the tuition charged for the entire program and shall not be entitled to any refund;
The enrollment agreement shall be signed by both the student and the authorized school official. For cancellation of the enrollment agreement referenced in (a) & (b), the “date of enrollment” will be the date that the enrollment agreement is signed by both the student and the school official, whichever is later.

Any inquiry a student may have regarding this contract may be made in writing to Oregon Medical Training, PCS, 1126 Gateway Loop, Suite 108, Springfield, OR 97477 or to the Superintendent of Public Instruction, Oregon Higher Education Coordinating Commission, 255 Capitol St. NE, Salem, OR 97310 or by calling (503) 947-5751.

I have read and received a copy of the enrollment agreement as required in OAR 715-045-0018 (1) (a-d). I have also read and received a copy of the following:

a) I have read the School Catalog. Search: www.oregonmedicaltraining.com/school-catalog *

Yes

b) I understand that I will receive and be required to sign a Release and Waiver of Liability the first day of class *

Yes

c) I understand that I need to purchase the required book and have it for the first day *

Yes

d) I submitted an application for a temporary Pharmacy Technician License through the Oregon State Board of Pharmacy *

Yes No, I am not applying for a pharmacy program

Your Signature *

Clear

Additionally, I understand the following:

After failure to attend class the first week, the school will attempt to contact the student via email and phone. It will then become the student’s responsibility to provide written notice to the school to cancel enrollment. If a registered student is absent from every day of class and has failed to notify Oregon Medical Training, PCS of the intended withdrawal after completion of 50% or more of the program, the student will forfeit registration, supply fee (if given supplies) and 50% tuition.

The tuition charges will accrue based on hours that the program is offered by the school and that I have contracted/scheduled to attend, rather than my actual attendance;
That any refund calculation is based on my last date of physical attendance; and;
Per OAR 715-0045-0008, Advanced Deposits, “Prior to the beginning of classes, no private career school shall require from an enrollee an advance deposit in excess of twenty (20) percent of the total tuition and fees:

Schools that offer short-term programs designed to be completed in one (1) term or four (4) months, whichever is less, can require payment of all tuition and fees on the first day instruction begins;
For those programs designed to be four (4) months or longer, a school cannot require more than one (1) term or four (4) months of advanced payment of tuition at a time. When fifty (50) percent of the program has been offered, the school can require payment of all tuition;
This limitation shall not apply to federal and state financial aid payments received by the school;
At the student’s option, a school may accept payment in full for tuition and fees after the student has been accepted and enrolled and the date for commencement of classes is specifically disclosed on the enrollment agreement.

MY SIGNATURE INDICATES THAT I HAVE RECEIVED THESE DOCUMENTS AND AGREE TO ANY STIPULATIONS LISTED IN THEM.

Terms and Conditions *

Today's Date *

Your Signature *

Clear

Required Student Information