Seminar Enrollment Agreement

Seminar Enrollment Agreement
School Name: Align Health Careers Institute, LLC

Address: 2080 N. Hwy. 360 #385

City: GRAND PRAIRIE State: TEXAS Zip: 75050

Telephone: (469) 984-6203 E-mail Address: ALIGNHEALTHCAREERS@GMAIL.COM
Student Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
Date

Course and Course Cost
Please select the seminar you wish to enroll in (SELECT ONE)
*Fee is estimated and based on current cost and subject to change.
Method of Payment (Check One)
Approved and regulated by the Texas Workforce Commission, Career Schools and Colleges, Austin, Texas.

Phlebotomy Release of Liability Form

The purpose of this document is to limit the amount of liability Align Health Careers Institute, LLC holds in regard to phlebotomy practices held on campus among students in the Phlebotomy Technician Program.
The following procedures are performed among students:

1. Phlebotomy – the inserting of a needle into the arm of another person for the purpose of withdrawing blood.
2. Finger Stick – the inserting of a lancet into the finger of another person for the purpose of withdrawing blood.

I UNDERSTAND AND HEREBY EXPRESSLY ACKNOWLEDGE that, as part of the instruction that I am to receive in the Phlebotomy Technician Program, I may be asked to perform phlebotomy and finger stick procedures or that another student may be asked to practice these procedures on me. Further, I understand and hereby expressly acknowledge that these activities might, under some circumstances, pose certain health-related risks.

I HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Align Health Careers Institute, LLC, its officers, directors, board members, agents, servants, employees, assigns, or successors, or students of the schools Phlebotomy Technician Program, from any and all liability, claims, demands, actions or causes of action arising out of any damage, loss or injury to my person or my property or resulting in my death, while enrolled in Align Health Careers Institute, LLC Phlebotomy Technician Program and participating in the activities contemplated by this RELEASE, whether such loss, damage, or injury is caused by the negligence of the training center, its officers, agents, servants, employees, assigns, or successors, or students of Align Health Careers Institute, LLC Phlebotomy Technician Program or from some other cause. I hereby assume full responsibility for and risk of bodily injury, death or property damage that I suffer while performing the above-stated procedures from Align Health Careers Institute, LLC Phlebotomy Technician Program or from any person involved, employed or representing Align Health Careers Institute, LLC Phlebotomy Technician Program and participating in the activities contemplated by this release, caused by the negligence of Align Health Careers Institute, LLC, its officers, directors, agents, servants, employees, assigns, or successors, or students of Align Health Careers Institute, LLC Phlebotomy Technician Program or otherwise.

I FURTHER UNDERSTAND that I may decline participation without penalty at any time. Consent to participate will allow me to perform the above-stated procedures on another member of the class and/or he or she may also perform those skills on me. All skills will be performed under the direct supervision of Align Health Careers Institute, LLC Phlebotomy Technician Program.

By signing this form, I am consenting to performing the procedures stated above and to having the above procedures performed on me and I am releasing Align Health Careers Institute, LLC from liability from any injury that might occur as a direct result from these procedures.

I HAVE READ AND VOLUNTARILY SIGN THE RELEASE AND WAIVER OF LIABILITY, and further agree that no oral representations, statements of inducement apart from the foregoing written agreement have been made. Further that I have read and that I understand this release of liability agreement, that I have been given an opportunity to ask any questions I might have had, and that those questions have been answered in a satisfactory manner. I also understand that I am free to withdraw my consent to the procedures at any time.

If the student is under 18 years of age, and not an emancipated individual, you must complete this form and it must be signed by a custodial parent or guardian.
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Student Signature
Parent or Guardian Signature, if applicable:
Date

MonthDayYear
Date

PHOTOGRAPHS/ VIDEO CONSENT, WAIVER, AND RELEASE
Student Name

First NameLast Name
I CONSENT AND GIVE PERMISSION TO Align Health Careers Institute, LLC to photograph and or video of self. I understand that any such photographs, and all rights associated with them, will belong solely and exclusively TO Align Health Careers Institute, LLC which shall have the absolute right to copyright, duplicate, reproduce, alter, display, distribute, and/or publish them in any manner, for any purpose, and in any form including, but not limited to, print, electronic, video, and/or Internet.

I voluntarily waive any and all rights with respect to any such photographs, including compensation, copyright, and privacy rights and any right to inspect or approve such photographs and/or copy, print or other materials that may be used in connection with them. I hereby release and discharge, and agree to hold harmless, Assured and Associates, its officers, agents and employees, and all persons acting under its permission or authority, from any TO Align Health Careers Institute, LLC claims and liability in connection with such photographs and/or their use.

I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS

CONSENT, WAIVER, AND RELEASE FORM, AND I SIGN IT FREELY AND

VOLUNTARILY.
Student Signature
Date

MonthDayYear
Date
Director Signature

For Office Use Only – Director Authorization, For Director use only. Students should leave this section blank.
Date

MonthDayYear
For Director use only. Students should leave this section blank.

Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.

If this application leads to enrollment, I understand that false or misleading information in my application or interview may result in my release.
Printed Name

First NameLast Name
Signature
Date

MonthDayYear
Date
Should be Empty:

Student Information

Course and Course Cost

Phlebotomy Release of Liability Form

PHOTOGRAPHS/ VIDEO CONSENT, WAIVER, AND RELEASE

Disclaimer and Signature