Pathway Medical Institute Registration Form

Pathway Medical Institute School Registration Form Student Information:

Name*

First NameLast Name

Date of Birth

Date

Address*

Number*

Email*

example@example.com

ELIGIBILITY FOR NATIONAL EXAMINATION

To be eligible to sit for the national exam, students must provide proof of one of the following:

* A valid, high school diploma or A valid, General Equivalency Diploma (GED) In addition, students must also provide a valid, government-issued ID.

Students who do not possess a high school diploma or GED may still enroll in the program for training purposes only. However, they will not be eligible to take the national exam until they have obtained one of the above-mentioned credentials.

It is the student's responsibility to obtain and provide proof of their high school diploma or GED, as well as a valid government-issued ID, prior to sitting for the national exam.

Failure to do so may result in ineligibility to take the exam (Name)*

Class Location

Program Selection (Please List the Program and Class Start Date) *

If a student withdraws from a course before it begins for any reason, they will be required to pay a $100 administration fee ( Type First and Last Name) *

Non-refundable deposit Deposit Information:

Phlebotomy:$250.00

EKG :$250.00

Certified Clinical Medical Assistant:$400.00

Dot and Specimen Collector $150

Deposit Amount (If you're receiving assistance , please provide name name)*

Payment Method:

Check Payable to Pathway Medical Institute

Credit Card (Visa, Mastercard, Amex) Processing Fee will be included

Cash or cash app

I hereby certify that the information provided is true and accurate. I understand that submission of this form does not guarantee acceptance into the program.

By submitting this form you acknowledge that you have read and understood the schools refund policy ( Type Name)*

Medical History: Please answer the following questions:

1. Do you have any allergies? Yes or no and If yes, please list:

If yes please list*

Emergency Contact Information: Please provide the name and contact information of someone who can be reached in case of an emergency

Name*

Phone*

Format: (000) 000-0000.

Relationship*

Email*

example@example.com

What is your highest level of education completed*

Date

OBLIGATION TO PAY FULL TUITION

The Student understands and agrees that, regardless of whether they withdraw from the program or not, they are responsible for paying the full tuition amount. The Institute will not waive or forgive any portion of the tuition, and the Student will be obligated to pay the full amount.

If the Student defaults on their payment obligations, the Institute reserves the right to take all necessary actions to collect the outstanding balance, including but not limited to, reporting the default to credit bureaus, sending the account to collections, and filing a lawsuit.

This Agreement shall be governed by and construed by the laws of Virginia. Any disputes arising out of this Agreement shall be resolved through binding arbitration by the rules of the American Arbitration Association.

This policy ensures that students who complete our program are fully prepared and have demonstrated the necessary skills and knowledge to receive our recommendation for employment. Students who withdraw from the program have not had the opportunity to complete the full curriculum and may not have the necessary qualifications for our recommendation.

Consequences of Dropping:

If a student drops from the program, they will not be able to:

* Receive a letter of recommendation from our school for employment
* Use our school's name or logo in any materials related to job applications
* Participate in any job fairs or other career services offered by our school

Exceptions:

In certain extenuating circumstances, the school may grant an exception to this policy. Students who wish to request an exception must provide documentation of their circumstances and submit a written request to the school administration at Sjonespathwaymedical@gmail.com

Unauthorized Use of Pathway Medical Institute Materials Prohibited

Any unauthorized use, reproduction, or distribution of Pathway Medical Institute's intellectual property, including but not limited to its name, logo, trademarks, service marks, copyrighted materials, and proprietary information, without the express written permission of Pathway Medical Institute is strictly prohibited.

Individuals or entities who engage in such unauthorized use will be subject to legal action, including but not limited to civil and criminal penalties. Pathway Medical Institute will vigorously protect its intellectual property rights and will not hesitate to take appropriate legal measures to enforce its rights.

If you are unsure whether a particular use of Pathway Medical Institute's intellectual property is authorized, please seek prior written approval from the institution.

This Agreement constitutes the entire agreement between the parties and supersedes all prior negotiations, understandings, and agreements between the parties. If you Agree Sign :

Date*

Date

Print Name*

Signature*

MEDICAL WAIVER AND RELEASE OF LIABILITY I hereby acknowledge that I am enrolling in the program at Pathway Medical Institute I understand that the School is not a medical facility and does not provide medical treatment or care*

I acknowledge that the program may involve certain risks including but not limited to exposure to infectious diseases physical injury and emotional distress. I understand that the school does not provide medical insurance or coverage for any medical treatment or care that I may require.*

I am responsible for seeking medical attention from a qualified healthcare provider if I require medical care or treatment*

In the event of a medical emergency I authorize the School to call emergency services and to provide basic first aid until medical professionals arrive I understand that the School is not liable for any actions taken in response to a medical emergency*

I understand that the School does not provide medical insurance or coverage for any medical treatment or care that I may require I am responsible for obtaining and maintaining my own medical insurance coverage*

School Acknowledgement

I acknowledge that I have read and understood this Medical Waiver and Release of Liability. I understand that by signing below, I am releasing the Released Parties from any and all claims, demands, actions, or causes of action that may arise from any medical treatment or care that I may require during my enrollment in the program.

I hereby acknowledge and agree to the terms of this Medical Waiver and Release of Liability.

Acknowledgment and Assumption of Risk:

I, the undersigned, hereby enroll in the Phlebotomy Training Program. I understand that this course involves practical training that includes the handling of needles, exposure to blood, and other related activities. I acknowledge that participating in this course carries certain risks, including but not limited to:

1. Needle stick injuries
2. Exposure to bloodborne pathogens
3. Allergic reactions
4. Bruising or bleeding
5. Other unforeseen risks

I voluntarily assume full responsibility for any risks of loss, property damage, or personal injury, including death, that may be sustained by me as a result of participating in this course, whether caused by the negligence of the training providers or otherwise.

Pathway Medical Institute will provide supplies. PLEASE READ THE Prohibited

1. Do Not Stick Anyone Under the Age of 18:

2. Do Not Use Expired Supplies:
- Ensure all needles and other supplies are within their expiration date before use.

3. Do Not Reuse Needles:
- Never reuse needles for any purpose. Each patient should receive a new, sterile needle.

4. Do Not Leave Needles Unattended:
- Never leave needles or sharp objects unattended in areas where they could pose a risk to others.

5. Do Not Recap Needles:
- Avoid recapping needles after use unless absolutely necessary. If recapping is required, use a one-handed technique to minimize the risk of needle sticks.

6. Do Not Overfill Sharps Containers:
- Ensure that sharps disposal containers are not filled beyond the designated fill line to prevent accidental needle sticks when disposing of used needles.

7. Do Not Use Improper Disposal Methods:
- Never dispose of needles or other sharps in regular trash or recycling bins. Always use designated sharps containers.

8. Do Not Ignore Signs of Infection:
- Do not proceed with venipuncture if there are signs of infection, such as redness, swelling, or pus at the site.

9. Do Not Use the Wrong Size Needle:
- Avoid using needles that are inappropriate for the patient's size or the type of procedure being performed.

10. Do Not Skip Hand Hygiene:
- Never neglect to perform hand hygiene before and after handling needles or performing phlebotomy procedures.

11. Do Not Engage in Horseplay:
- Avoid any form of horseplay or distractions in areas where needles and other sharp instruments are being handled.

12. Do Not Ignore Patient Comfort and Consent:
- Ensure that patients understand the procedure and consent to it. Avoid performing venipuncture without explaining the process.

Tuition Payment Agreement Read Below.

Attention!! For the Phlebotomy Program the remaining balance must be settled through either weekly or biweekly payments and must be paid by the 4th class meeting. For the CCMA Program , payments can be made monthly, biweekly, or weekly, with the total amount due by the 4th month of class. Ensure that all payment dates align with your class schedule before submitting your form. If you have any questions regarding the due dates, please reach out to Mrs. Jones at sjonespathwaymedical@gmail.com. ( Initial) *

CCMA Payment (Choose one of the following payment plans or opt to Pay in full)

Registration Fee: $400 (due at the time of registration)

Balance: $1,900 Due by the 4th month of Class

- Weekly Payments: $118.75 for 16 weeks

- Biweekly Payments: $237.50 every two weeks for 8 payments

- Monthly Payments: $475.00 for 4 months, 4 Payments

Payment Plan Your Selecting *

Attention Future Students

Please be aware that once the registration form is submitted, students will receive a welcome letter and Registration Pay link. Please read over your welcome letter and provide all necessary information to our Director of Admissions.

If the Student fails to make the agreed payments by the deadlines, the institute reserves the right to take appropriate action, including charging late or check return fees, terminating the Student's enrollment, or pursuing collection of the outstanding balance.

Acceptance of Terms By signing below, both parties acknowledge that they have read and understood this Tuition Payment Agreement and agree to abide by its contract.

By Providng your Signature you agree to all terms and conditions of the School Acknowledgement*

Date*

Date