EMERGE PULSE TRAINING INSTITUTE
SEPTEMBER RESET - STUDENT ENROLLMENT & AGREEMENT
Please complete all sections and review the enrollment terms before signing.
1. Student Information
Legal Name:
First Name
Last Name
Preferred Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Street Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City / State / ZIP:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name:
First Name
Last Name
Relationship:
Phone Number:
Format: (000) 000-0000.
Highest education completed:
High School Diploma / GED:
Yes
No
Photo ID:
Attached / Uploaded
Will provide to Emerge Pulse
2. September 2026 Course Selection
September 2026 Course Selection
Rows
Course
Start Date
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
September Reset Tuition:
ONE course - $550 total
TWO courses - $600 total
One-course enrollment fee: $50 non-refundable. Two-course enrollment/application fee: $75 non-refundable.
Amount paid today:
Remaining balance:
Payment method:
Cash App
Apple Pay
Venmo
Other
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Preferred format where available:
Preferred format where available:
Day
Evening
Online
Hybrid
3. Transportation
Do you need Emerge Pulse Ride transportation?
Yes
No
Emerge Pulse Ride is $25 round-trip within a 20-mile radius and is subject to availability.
4. Program Information & Requirements
• EKG Technician: 4-week program. Red scrubs and black shoes.
• Phlebotomy Technician: 4-week hybrid program; Weeks 1-2 online and Weeks 3-4 clinical. Clinical requirements include 30
venipunctures and 10 capillary sticks. Red scrubs and black shoes.
• Medical Assistant: 8-week hybrid program with 4 online weeks and 4 clinical weeks. Black scrubs and black shoes during the clinical
portion; stethoscope and blood-pressure cuff required.
• Billing & Coding: Online program.
• Medical Office Assistant: Online program.
• Google Classroom and instructor information are generally sent shortly before class. Students should check spam/junk folders.
• Eligible programs may prepare students for NHA national certification. The NHA exam fee is separate and currently $129 unless
otherwise stated in writing. Passing a certification exam is not guaranteed.
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5. Student Acknowledgements
I understand that the enrollment/application fee is non-refundable.
I understand my tuition amount, payment obligations, and remaining balance.
I understand my seat is not secured until the required enrollment payment is received.
[] I am responsible for attendance, assignments, clinical requirements, uniforms, supplies, and other requirements applicable to my program.
I understand schedules may be subject to reasonable operational changes with notice.
I understand certification exam fees are separate unless specifically stated otherwise in writing.
I will provide accurate contact information and a valid photo ID.
I agree to follow Emerge Pulse Training Institute policies and professional conduct expectations.
6. Funding Assistance
Are you seeking SNAP / DCFS / OFS funding assistance?
Yes
No
Unsure
If yes, additional documentation and eligibility requirements may apply.
7. Student Certification & Signature
I certify that the information I provided is accurate. I have reviewed my selected course(s), start date(s), tuition, fees, payment responsibilities, and applicable program requirements. By signing below, I agree to the Emerge Pulse Training Institute enrollment terms and student policies.
Student Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Name:
First Name
Last Name
Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
8. Emerge Pulse Staff Use Only
Enrollment received:
Photo ID received:
Yes
No
Fee received:
Amount paid:
Balance due:
Payment plan:
Selected course(s):
Staff initials:
Notes:
Emerge Pulse Training Institute | 337-592-3854 | emergepulsetraininginstitute.com
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