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 Name
Middle Name
Last Name
Preferred Name (if different from above)
What are your pronouns?
She/Her/Hers
He/Him/His
They/Them/Theirs
Other
Please select the program(s) you are applying for
*
Phlebotomy Technician
EKG Technician
Pharmacy Technician
How did you find out about us?
Web Search
Facebook
Instagram
Referral
Are you 18 years of age or older?
*
Yes
No
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
(###-##-####)
Emergency Contact
*
First Name
Last Name
Emergency Contact
*
Please enter a valid phone number.
Gender
*
Male
Female
Other
Race
*
Asian
African American
Hispanic or Latino
Native American or Alaskan Native
Native Hawaiian or Pacific Islander
Caucasian
Other
Are you a U.S. Citizen?
*
Yes
No
Are you an Oregon resident?
*
Yes
No
Are you disabled?
*
Yes
No
Are you a U.S. Veteran?
*
Yes
No
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence
*
Which document did you obtain?
*
U.S. High School Diploma
International High School Diploma
General 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
*
Browse Files
Drag and drop files here
Choose a file
We will accept: Drivers License, State issued ID card, Birth Certificate, or Passport
Cancel
of
Please upload your High School Diploma
*
Browse Files
Drag and drop files here
Choose a file
We will accept: High School Diploma, High School Transcript, or GED Certificate
Cancel
of
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.
*
Yes
No, I am not applying for a pharmacy program
I agree to the Terms and Conditions and this is a binding contract
*
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 class
No, a financial agency, i.e., STEP or the SEIU-UHW Joint Employer Education Fund will pay my fees and tuition
Signature
*
Date
*
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SECTION 2: To Be Completed By Authorized Representative
The school administrator will review the student information and sign below. Please leave blank and press “submit”.
Authorized School Official
First Name
Last Name
Signature
Date
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Submit
Should be Empty: