Online Enrollment/Registration Form

Online Enrollment/Registration Form

ALL PROGRAMS HAVE A $500 DEPOSIT DUE AT REGISTRATION
HOURS OF OPERATION

Monday: 9am-4pm & 6pm-9pm

Tuesday: 8:30am-12:30pm & 6pm-9pm

Wednesday: 9am-4pm & 6pm-9pm

Thursday: 8:30am-12:30pm & 6pm-9pm

Friday 9am-3:30pm

Saturday: 9am-6pm

Sundays: CLOSED
Basic Information

Please fill out the information below
Todays Date*

MonthDayYear
Date
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Relationship to contact*
Program information

Please indicate which program you are applying to, and specify which days and times that you are enrolling for. Information about program dates and times are available at https://www.marosaschoolofphlebotomy.com/
Program you are enrolling to*

Certified PhlebotomyCertified Medical AssistantCertified Patient Care TechnicianCertified EKG TechnicianCertified Medical Billing & CodingRefresher Course Training (Medical Assisting, Phlebotomy, Patient Care Technician)I.V. Training CourseSummer Teen Special
Which Class times are you doing? (example: I am doing Monday & Wednesdays 6:00-9:00pm for the Phlebotomy Program)*
IMMUNIZATIONS!

Being in HANDS ON programs, you will be participating in lab with fellow students. Participation involves the engagement in laboratory skills and procedures with other classmates, which involves many different aspects of laboratory training, and the handling of bodily fluids ;It is our duty to make sure you are prepared to participate in the laboratory setting; therefore, the following immunizations will be needed to start clinical laboratory procedures: Hepatitis B Vaccine (Medical Assistant, PCT, and Phlebotomy students only)TB Vaccine (Medical Assistant, PCT, and Phlebotomy students only)
Please check the following IF IT APPLIES TO YOU*

I have had a Hepatitis B vaccine within the last 12 months (please provide proof by week 3)I have not had a Hepatitis B vaccine (if you have not, it is mandatory before you participate in live laboratory procedures)I will sign a waiver form for the Hepatitis B vaccinationI can participate in all laboratory procedures and be drawn onI do not have any serious skin conditionsI do not have sclerosed veinsI have not had a heart attack or stroke in the last yearI am not a coumadin/warfarin patientI make sure that I am well hydratedI do not have any latex allergiesI am allergic to latexI do not have panic/anxiety attacksI do have panic/anxiety attacksI do have health insuranceI do not have health insurance
Do you have any restrictions that will prohibit you from participating in laboratory procedures? If so, please explain below:*
What medical training or experience have you had in the past?*
Reference Name*

First NameLast Name
Reference phone number*
Please enter a valid phone number.
Dress code

Shoe attire for clinical programs should be puncture resistant shoes, clogs, or any type of protective wear for your feet. However, all uniforms, when coming to class must always be neat and clean. If you are wearing white shoes, they must be kept clean. ****FOR ALL CLINICAL PROGRAMS-PLEASE BE REMINDED THAT IF YOU DO NOT HAVE ON SCRUBS, YOU CANNOT PARTICIPATE IN INVASIVE LABS OR PROCEDURES! ****
Signature (if under 18 parents must sign)*

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Online Enrollment/Registration Form

Basic Information

Program information

IMMUNIZATIONS!

Dress code

Credit Card