School Registration Form

School Registration
Divine Phlebotomy Training
Things to remember

Please contact the school immediately if a situation arise that you cannot continue your course.

• All tuition are to be paid in full prior to sitting for your exam.
• Once your application is received an invoice will be sent to you for payment.
• If full tuition is not received you would not be able to obtain your licensure.
• Clinicals are to be completed prior to taking your National Examination.

we do ask for a 250$ enrollment fee to secure your seat in class. All class are online and is Self Pace. please contact administration at 407-792-8156 in you have any questions.
Student Information
Name

First NameLast Name
SSN
Birth Date

MonthDayYear
Gender
Ethnicity
Email Address
Phone Number
Please enter a valid phone number.
Have you previously applied to or attended this school?

YesNo
If yes, what year?
Current Residence Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Primary Residence Information (if different from above)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Residence Information (if different from above)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact 1
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Emergency Contact 2
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Physician and Medical Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.

Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
Should be Empty: