FLIP ACADEMY — PHLEBOTOMY CLASS ENROLLMENT FORM

Form

Flip Phlebotomy Registration Form
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Email Address
example@example.com
Phlebotomy Technician
Emergency Contact (Name & Phone)
Program Details
📅 6-Day Phlebotomy Class:
Choose Your Class Date
Have you ever taken a phlebotomy or medical course before?
How did you hear about F.L.I.P. Academy?
Tuition & Policies
Tuition is $950 with a $150 non-refundable registration fee. Refunds are only available if cancellation is made at least 7 days before class start.
Preferred Payment Method for Tuition

Other

Deposit Only (Non-Refundable)

Secures your seat. Goes toward tuition balance.

$150.00

Full Tuition (One-Time Payment)

“$950 tuition – $150 New Year discount = $800 total. Includes training, and supplies.

$800.00

Total

Credit Card

Apple Pay

Cash App Pay

Afterpay

Agreement & Signature
Terms
✅This is a 6-day, in-person Phlebotomy course held over two weekends (Friday–Sunday, Friday–Sunday).
Tuition is $950, which includes a $150 non-refundable registration fee.
Your seat is only confirmed once payment has been received.
You must attend all sessions to receive credit for course completion and certification eligibility. You will be contacted within 24 hours to finalize your enrollment.
I agree to the terms above.
National Certification Exam (Optional)

The $119 National Certification Exam fee is not included in your tuition.This payment is made separately on exam day — please bring a debit or credit card for payment.Your instructor will guide you through the registration process.
Would you like to register for the National Phlebotomy Certification Exam?
Signature
Section 5: File Upload (Required)
Upload your photo ID ( REQUIRED)

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