Course Registration

Certified Phlebotomy Technician

4-Week Course Registration Form (non-refundable registration fee required)
Name*

First NameLast Name
E-mail*
example@example.com
Date of Birth*

MonthDayYear
Date
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Number*
Please enter a valid phone number.
Emergency Contact*

First NameLast Name
High School Attended*
Graduation/GED Year*

MonthDayYear
Date
How Did You Hear About Us?*

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Class format

In-Person
Choose Class Schedule

Night Mon/Wed (March 30th)Morning Mon/Wed (March 30th)Night Mon/Wed (April 27th)Morning Mon/Wed (April 27th)Night Mon/Wed (June 1st)Morning Mon/Wed (June 1st)Night Mon/Wed (June 29th)Morning Mon/Wed (June 29th)Night Mon/Wed (July 27th)Morning Mon/Wed (July 27th)
Payment

Payment Options*

Full Tuition

$1,750.00

Non-Refundable Registration Fee

By choosing this option, you will have 3 remaining payments to complete on a Bi-weekly basis (every 2 weeks) via automatic invoice.

$440.00

Total

$0.00

Credit Card

Apple Pay

Google Pay

Certified Phlebotomy Technician