Castor Health Institute, LLC

417 E 3rd St., Ste. B

Sterling, IL 61081

815-622-3550

https://www.castorhealthinstitute.com

email: info@castorhealthinstitute.com

 
Freeport Office

30 E. Stephenson St.

Freeport, IL 61032

THIS IS THE ENROLLMENT FORM FOR THE PHLEBOTOMY COURSE. IF YOU MEANT TO INSTEAD ENROLL IN THE CERTIFIED NURSING ASSISTANT (CNA) COURSE, PLEASE GO BACK AND SELECT THE CNA ENROLLMENT FORM INSTEAD.

You must be 16 or older to enroll. You must have completed high school or your GED to enroll.

We're excited to bring you into our class! Please double-check all fields before clicking "submit" at the end.

To complete this form, you will need a photo or scan of the following documents:

• State ID or Drivers License
• Social Security Card

We will also optionally need a scanned verification of a tuberculosis test. If you have been tested and have the documentation, you will be asked to upload it here. If you don't have it, no worries! We can get that taken care of later on.

No payments will be collected at this time. At the end of this form, you'll be asked to schedule an in-person enrollment appointment. The enrollment fee will be collected at that appointment, and payment plans will be discussed then.

PHLEBOTOMY TECHNICIAN PROGRAM:

This program meets the needs of students with no prior knowledge or experience in
Phlebotomy. Training provided consists of lecture and hands on lab time. The program is designed to allow the most qualified healthcare professionals to become qualified certified phlebotomists. The Phlebotomy course will explain the role of the phlebotomy technician; explain basic anatomy and physiology of the circulatory system; define standard precautions and apply its principles to all procedures; list methods of client and specimen identification; describe proper bedside manner and how to prepare the client for venipuncture collection; identify appropriate locations for venipuncture collection; and explain potential risks and complications. Students must provide evidence of successful performance of a minimum of thirty (30) venipunctures and ten (10) capillary sticks on live individuals. After successful completion of the program the student is eligible to sit for the National Phlebotomy Certification Examination (NPCE).

ADMISSION REQUIREMENTS:

To be admitted into the Castor Phlebotomy Technician Course the student must meet the following requirements:

• Must be 16 years of age or older
• Must have a high school diploma or GED
• Required criminal background check – In compliance with the Health Care Worker Background Check Act. Applicants with disqualifying felony convictions will need to obtain a Waiver from the Illinois Department of Public Health.
• Two step TB skin tests or a QuantiFERON-TB gold blood test
• State issued picture ID and social security card
• Complete and signed Enrollment Agreement and payment/voucher received by the institute

ATTENDANCE REQUIREMENTS:
This training program is an intensive, accelerated, 60-hour program. Students must attend all sessions to graduate. Please be sure to make all arrangements to attend classes prior to class starting.

ITEMIZATION & TOTAL TUITION FEES

TUITION FEE: $1,350

ADDITIONAL TUITION FEE IF PAYING ON PAYMENT PLAN: $100

NONREFUNDABLE REGISTRATION FEE: $175 (includes textbook, supplies, and admin fees)

PAYMENT DEADLINES AND MISSED PAYMENTS

The nonrefundable registration and supplies fees must be paid during the enrollment appointment. The tuition fee must be paid before the first day of class, if paying in full, or by the agreed upon payment plan deadlines, if paying on a payment plan.

If any payment is not made by its deadline, the school has the right to terminate the student from the course which the student is enrolled in or currently attending. If a payment is then made at a later date or time, the school may, at the school's discretion, and circumstances permitting, allow the student to attend a future course session.

REFUND POLICY:

• A notice of cancellation must be in writing
• This is an accelerated program; no refund will be given if cancellation is obtained 4 business days prior to or after the first day of class.
• When notice of cancellation is given 5 business days prior to the first day of class, students will be refunded any tuition minus the non-refundable $175.00 registration fee.

DRESS CODE:

• All students must wear scrubs during classroom hours.
• All students must wear closed toe and closed heel shoes during classroom hours.
• All students must wear their hair up if the hair length is longer than shoulder length.
• Acrylic nails are not permitted. Nails must be trimmed to 1⁄4” or shorter. Nail polish should not be chipped or cracked.
• Lab coats should be worn during clinical/lab hours.
• PPE should be worn at all times during clinical/lab hours.

CODE OF CONDUCT:

• Be respectful of the property and others. Try to arrive at least 5 minutes early for class.
• Students are to adhere to the dress code during all classroom and clinical hours.
• Horseplay will not be tolerated. You can be removed from the program if you are a danger to others.
• Safety must be a priority for all students.

REPORTING STUDENT COMPLAINTS
ILLINOIS BOARD OF HIGHER EDUCATION
1 N. OLD STATE CAPITAL PLAZA, SUITE 333
SPRINGFIELD, IL. 62701
217-782-2551
www.complaint.ibhe.org

NOTICE TO STUDENT

• Do not sign this agreement before you have read it or if contains any blank spaces
• This agreement is a legally binding instrument and is only binding when the agreement is accepted, signed, dated by all authorized officials of the school or the admissions officer at the school’s principal place of business. Read all pages of this contract before signing.
• You are entitled to a copy of the agreement and any disclosure pages you sign.
• This agreement and the school catalog constitute the entire agreement between the student and the school.
• Any changes in this agreement must be made in writing and shall not be binding on either the student or the school unless such changes have been approved in writing by the authorized official of the school and by the student or the student’s parent or guardian. All terms and conditions of the agreement are not subject to amendment or modification by oral agreement.
• The school does not guarantee the transferability of credits to another school, college, or university. Credits or coursework are not likely to transfer: any decision on the comparability, appropriateness and applicability of credit and whether credit should be accepted is the decision of the receiving institution.

1. I hereby acknowledge receipt of the school’s catalog, which contains information
describing programs offered, and equipment or supplies provided. The school
catalog is included as part of this enrollment agreement, and I acknowledge that I
have received a copy of this catalog.

2. I have carefully read and received an exact copy of this enrollment agreement.

3. I understand that the school may terminate my enrollment if I fail to comply with attendance, academic, and financial requirements or if I fail to abide by established standards of conduct, as outlined in the school catalog. While enrolled in the school, I understand that I must maintain satisfactory academic progress as described in the school catalog and that my financial obligation to the school must be paid in full before a certificate or credential may be awarded.

4. I hereby acknowledge that the school has made available to me all required disclosure information listed under the Consumer Information section of this Enrollment Agreement.

5. I understand that the school does not guarantee transferability of credit and that in most cases, credits or coursework are not likely to transfer to another institution. In cases where transferability is guaranteed, Castor Health Institute must provide me copies of transfer agreements that name the exact institution(s) and include agreement details and limitations.

6. I understand that the school does not guarantee job placement to graduates upon program completion.

7. I understand that complaints, which cannot be resolved by direct negotiation with the school in accordance to its written grievance policy, may be filed with the Illinois Board of Higher Education, 1N. Old State Capitol Plaza Suite 333 Springfield, IL 62701 or at www.ibhe.org.

The student acknowledges receiving a copy of this completed agreement, the school catalog, and written confirmation of acceptance prior to signing this contract. The student by signing this contract acknowledges that he/she has read this contract, understands the terms and conditions, and agrees to the conditions outlined in this contract. It is further understood that this agreement supersedes all prior or contemporaneous verbal or written agreements and may not be modified without the written agreement of the student and the School Official. The student and the school will retain a copy of this agreement.

Illinois Department of Public Health

Health Care Worker Background Check Authorization and Disclosure for Criminal History Records Information (CHRI) Check

I hereby authorize the Illinois Department of Public Health (the Department), the Department's designee, educational entities that train and/or test health care workers, staffing agencies, my current or potential employer, or a health care facility where I want to volunteer to initiate/request a CHRI check on me. I further authorize the Illinois State Police (ISP) and/or the Federal Bureau of Investigation (FBI) to release information and photographs relative to the existence or nonexistence of any criminal record, which it might have concerning me, to any initiator/requestor solely to determine my suitability for training or testing in a health care training program, employment, continued employment, or to work as a volunteer. I further authorize any entity that maintains criminal records and photographs relating to me, including but not limited to a local unit of government in any State, to release those records and photographs to the ISP, FBI, or the Department. I authorize the Department to provide any health care facility, training program or staffing agency, to which have provided this authorization and disclosure form, a copy of my ISP CHRI and a determination of eligibility of the ICHRI. I certify that the ISP, FBI, any entity that maintains criminal records and photographs, the Department, and any of their employees or officers who furnish this information shall be held harmless from all liability, which may be incurred as a result of releasing such information. I further acknowledge that a educational entity or a health care employer shall not be liable for the failure to hire or retain me as an applicant, student, employee, or volunteer ifI have been convicted of committing or attempting to commit one or more of the offenses stated in the Health Care Worker Background Check Act (225 ILCS 46/25

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I understand that any false statements or deliberate omissions on this document may be grounds for disqualification from employment, training, or volunteering, if discovered after employment, training, or volunteering begins, and can result in discipline up to and including my termination of employment, being a volunteer, or a student.

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I understand that the information requested below regarding gender, race, height, eye color, hair color, weight, place of birth and date of birth is for the sole purpose of identification and the accurate gathering of the criminal history record information, and that it will not be used to discriminate against me in violation of the law. I understand that the provision of my Social Security number is required by law. A facsimile or photographic copy of this authorization will be as valid as the original.

A - Chinese, Japanese, Filipino, Korean, Polynesian, Indian, Indonesian, Asian Indian, Samoan, or any other Pacific Islander.

B - Black or African American (Not Hispanic or Latino)

H - Hispanic or Latino (Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin), American Indian, Eskimo, or Alaskan native, or a person having origins in any of the 48 contiguous states of the United States or Alaska who maintains cultural identification through tribal affiliation or community recognition.

U - Of undeterminable race. Of Untold mixture.

W - Caucasian (not Hispanic or Latino)

I certify that all information I have provided above is true and correct.

Take a photo or make a scan of the following documents and upload them here. Make sure they are clearly visible and readable.

READ CAREFULLY:

To finalize your enrollment, you will need to come in-person to our Sterling office for a short appointment. During the appointment, we will get to know you, verify your identity, address any questions you may have, and discuss payment and payment plans.

The best option is to come in during one of our ENROLLMENT DAYS.

If you cannot make any of the enrollment days, then we will reach out to you to schedule your enrollment appointment.

For your appointment, you will need to bring:

• Your State ID or Drivers License
• Your Social Security card
• [Optionally] Your tuberculosis test
• Your nonrefundable enrollment fee of $175 (we accept card, cash, or check)

All appointments are at the Freeport office:

30 E. Stephenson St.

Freeport, IL 61032

Soon after submitting this form, you will receive an email with the above information concerning your enrollment appointment.

If you marked "Yes" to being interested in applying for financial assistance, you will also receive information on that as well.