Phlebotomy Registration Form

PHLEBOTOMY TRAINING AND CERTIFICATION CENTER

Phlebotomy Class Registration Form
Student Name

First NameLast Name
Student Email
example@example.com
Student Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Class
Class Times
The cost of the Phlebotomy course is $1,700 for a two-week program.

A $500 deposit is required and can be paid through Cash App, Zelle, or credit card. Please note that credit card payments will incur a 3.7% convenience fee. The $500 deposit is non-refundable if a student decides to withdraw from the course.

Classes are held Monday through Thursday from 5:00 PM to 9:00 PM.

Thank you,
Esilda Prentice
Director
Student Signature
Should be Empty:

PHLEBOTOMY TRAINING AND CERTIFICATION CENTER