Short-Term Training: Phlebotomy Release

Short-Term Training

Phlebotomy Release
All Phlebotomy students are required to pass a State of Michigan background check. Criminal background records of felonies and certain misdemeanors are not allowed into the Phlebotomy Short-Term Training. You should refer to the Public Health Code to see the Michigan background restrictions for health occupations.

I understand that Mid Michigan College may obtain and review conviction criminal history information for my participation in Phlebotomy Short-Term Training. This will ensure program eligibility but does not guarantee employment by a healthcare facility. I release the following information and consent to its use for this purpose.
Full Legal Name*

First NameMiddle NameLast Name
Other Legal Name

First NameMiddle NameLast Name
Other Legal Name

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Email*
example@example.com
Sex Assigned at Birth*

MaleFemale
Gender Identity*

MaleFemaleNon-Binary/Third GenderPrefer to Self-DescribeOther
Race*

African American or BlackAmerican Indian or Alaska NativeHispanic or LatinoNative Hawaiian or Other Pacific IslanderHispanic or ChicanoWhite or CaucasianTwo or More RacesOther
CRIMINAL BACKGROUND CHECK / DRUG AND ALCOHOL SCREENING

Applicants with a felony, certain misdemeanors and positive drug screening may not be admitted to any Health Sciences program of study.
Have you ever been convicted of a felony?*

YesNo
Check all of the following that you have been convicted of:*

Misdemeanor involving the illegal delivery of alcohol or a controlled substance.Misdemeanor against a vulnerable child / adult.Misdemeanor for assault and/or battery.Misdemeanor for fraud or embezzlement.Misdemeanor for contributing to a minor.Misdemeanor for sexual misconduct.None of the above.
Have you ever been convicted of a misdemeanor punishable by imprisonment?*

YesNo
Have you been treated for substance abuse in the past two years?*

YesNo
I understand that the above information is required by the Central Records Division of the Michigan State Police in Lansing, Michigan. I authorize Mid Michigan College to obtain my conviction criminal history information and report information as required.

Prior to being accepted into Phlebotomy Short-Term Training, students must undergo a criminal background check in accordance with state regulations. If a record is found for a felony or misdemeanor the student may not be allowed to participate.
Signature*

Clear
Today's Date*

MonthDayYear
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