Enrollment Form

Enrollment Form

If you have any questions, you may contact us at (541) 343-3100 during business hours or by email at admin@orphleb.com. Required Student Information - in accordance with OAR 715-045-0018
SECTION 1: Student Information
Name*

First NameMiddle NameLast Name
Preferred Name (if different from above)
What are your pronouns?

She/Her/HersHe/Him/HisThey/Them/TheirsOther
Please select the program(s) you are applying for*

Phlebotomy TechnicianEKG TechnicianPharmacy Technician
How did you find out about us?

Web SearchFacebookInstagramOther
Are you 18 years of age or older?*

YesNo
Date of Birth*

MonthDayYear
Date
Social Security Number
(###-##-####)
Emergency Contact*

First NameLast Name
Emergency Contact*
Please enter a valid phone number.
Gender*

FemaleMaleOther
Race*

Asian or Pacific IslanderBlack or African AmericanHispanic or LatinoNative American or Alaskan NativeWhite or CaucasianMultiracial or BiracialOther
Are you a U.S. Citizen?*

YesNo
Are you an Oregon resident?*

YesNo
Are you disabled?*

YesNo
Are you a U.S. Veteran?*

YesNo
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence*
Which document did you obtain?*

U.S. High School DiplomaInternational High School DiplomaGeneral Educational Development Test (GED)I did not obtain any diploma or any GED equivalency
What year did you graduate high school or equivalency?*
What high school did you graduate from?*
or last attend
What is your high school code?*
Search: https://nces.ed.gov/ccd/schoolsearch/ If obtained a GED certificate, please write in N/A
Please upload your proof of Identification*

We will accept: Drivers License, State issued ID card, Birth Certificate, or Passport
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Please upload your High School Diploma*

We will accept: High School Diploma, High School Transcript, or GED Certificate
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Please select responsible party making tuition payments*

I am working with Worksource Lane, STEP counselor or similar financial support agency.I am working with the SEIU-UHW Joint Employer Education Fund.I will be responsible for making tuition payments.
If you selected “working with financial support agency” above, please enter counselor name and agency.*

I am not working with an agency.I am working with the SEIU-UHW Joint Employer Education Fund.Click here to enter name of counselor and agency
I understand that if I do not pay the full tuition costs by 50% of course completion it will result in Academic Suspension or Termination*

Yes
I have read the School Catalog*

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

Yes
I understand that I need to purchase (or rent) the required book and have it by the first day of class*

Yes
I will submit an application for a temporary Pharmacy Technician License through the Oregon State Board of Pharmacy as soon as I am enrolled.*

YesNo, I am not applying for a pharmacy program
I agree to the Terms and Conditions*

Yes
I will pay, at the minimum, my registration and supply fee on the next page.*

Yes, I understand this will reserve my seat in classNo, a financial agency, i.e., STEP or the SEIU-UHW Joint Employer Education Fund will pay my fees and tuition
Signature* Date*

Enrollment Form

SECTION 1: Student Information

SECTION 2: To Be Completed By Authorized Representative