Phlebotomy WCE Registration Form

Phlebotomy Registration Form

Office phone: 903-693-2067 email: ce@panola.edu
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PhlebotomyJanuary 21st-April 15th, 2025; Tuesdays 5:00PM - 8:15PM
$1,175.00

Total

$0.00
Name*

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Are you a high school student? If so, you MUST contact Wendy Green at 903-693-1197 or wgreen@panola.edu in order to be registered for this class.

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Ethnicity and Race
Are you Hispanic or Latino? (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)*

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Please select the racial category or categories with which you most closely identify. Check as many as apply.*

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Special Population Information
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NoneDisabledHomelessYouth whose parent is active duty armed forcesSIngle parent, including single pregnant womenEconomically disadvantaged families, including low-income youth and adultsOut-of-workforceYouth in or aged out of foster careIndividual lpreparing for nontraditional fieldBarriers to educational achievment, including limited English proficiency
I give Panola College permission to release my directory information.*

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I agree to abide by the college copyright agreement and release. I also affirm that policies concerning disclosure of directory information as well as information related to Bacterial Meningitis (Senate Bill 31) were made available.*

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Phlebotomy Certificate Program

Phlebotomy I:	90 Classroom Hours/Lab hours	Cost: $1175
Phlebotomy II:	150 Clinical hours (Red scrubs required)
CPR (BLS):	Included in course fee
AMT Testing Fee:	Included in course fee

Registration Requirements:

High School diploma/GED
Driver's license or State issued ID
Social Security card
Criminal Background check and Drug Screening
Proof of immunizations

Students must take and pass both sections to complete the course. These courses will provide 90 hours of classroom lectures/lab hours in a classroom setting, and 150 hours of on-site clinical training. Prior to the clinical portion of the program, students must have certification in BLS for Health Care Provider CPR and proof of immunizations listed below.

After successful completion of the 240 hours, students will register for their state certification exam through American Medical Technologists (AMT).

Students must provide proof of the following immunizations:

Varicella
Measles, Mumps, Rubella (MMR)
Hepatitis B vaccine
Tetanus/ Diphtheria (Tdap- within 10 years)
Influenza
Negative TB skin test/ chest x-ray (within the last year)

If a student cannot provide proof of the vaccine, they will need to have the titer test done to check for the following antibodies:

Varicella IgG
Rubeola IgG
Mumps IgG
Rubella IgG
Hepatitis B Quant

Consent for Background Check and Drug Screening
Signature

Clear
PHLEBOTOMY

BACKGROUND/DRUG SCREENING

I give Panola College permission to perform a background search from the following websites prior to registering for the Phlebotomy program:
1.    Public Data
2.    Texas Department of Public Safety – Criminal History background

If I am married or have been married and divorced, I also give Panola College permission to perform a Criminal Background check on my maiden name as well as my married name(s). My admission into the Phlebotomy program is ultimately determined by the findings of the above searches and those findings will be final.

I, First Name   Last Name , recognize that the use and abuse of alcohol, drugs or substances can create an unsafe clinical working environment for others and myself. When requested, I agree to provide a blood, urine and/or breath sample to a drug-testing laboratory designated by Panola College. I also permit the testing laboratory to release the results of the drug-screening test to designated Panola College authorities.

I give permission to Panola College authorities to verify my prescription medications with the prescribing health care provider.

I give Panola College Phlebotomy program permission to give copies of the results of my drug screening and/or criminal background check to the Clinical Supervisor, Director of Nursing or Clinical Human Resource Department at the site I am attending, when requested.

FULL NAME   LAST*   FIRST*   MIDDLE   MAIDEN
Other names used
Date of Birth*      RACE*   Gender*
Signature

Clear
PHLEBOTOMY PROGRAM ELIGIBILITY INFORMATION

Criminal Background Check

Successful completion of a criminal background check is required for admission into the Panola College Phlebotomy program. The background check will include a seven year felony and misdemeanor criminal record search.

The following histories will disqualify an individual from consideration for admission because the student would not be eligible for clinical placement: (this includes, but is not limited to):
- Registered sex offenders
- Felony convictions
- Felony deferred adjudication involving crimes against persons (physical or sexual abuse)
- Known or observed abuse or neglect of patients/clients/customers
- Observed or proven theft
- Convictions of violent acts (misdemeanors or felonies)
- Misapplication of fiduciary property or property of a financial institution (Class A misdemeanor or felony)
- Securing execution of a document by deception (Class A demeanor or felony)
Disclaimers
- Successful completion of a background check does not ensure eligibility for licensure or future employment.
- Clinical agencies can establish more stringent standards, if they so desire, to meet regulatory requirements for their facility.
- Clinical agencies can conduct additional background checks at their discretion.
- If a student is found to be ineligible for clinical placement at any time during the program, the student is unable to meet clinical learning objectives and will be withdrawn from the program.
Name

First NameLast Name
Signature

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Please upload photo of your Drivers License or State ID, Social Security Card, High School Diploma/GED Certificate, and any other information requested.

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PAYMENT INFORMATION

Please call 903-693-2067 to pay for your class and complete your registration.
Signature

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Should be Empty:

Phlebotomy Registration Form

Ethnicity and Race

Special Population Information

Phlebotomy Certificate Program

Consent for Background Check and Drug Screening

PHLEBOTOMY

BACKGROUND/DRUG SCREENING

PHLEBOTOMY PROGRAM ELIGIBILITY INFORMATION

Criminal Background Check

Disclaimers

PAYMENT INFORMATION