Student Registration Form
Name
*
First
MI
Last
Maiden Name
Address
*
Street Address
City
State / Province
Zip Code
Phone Number
*
-
Area Code
Phone Number
Phone Type
*
Mobile
Home
Email Address
*
Course Time
*
Mid-Morning (10:00-2:00)
Program
*
Phlebotomy (April 7th)
Phlebotomy (June 2nd)
Phlebotomy (August 4th)
Phlebotomy (September 22nd)
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More Info
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Is English your native language?
*
Yes
No
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Background
Lillie's Institute of Phlebotomy/EKG collects, reports, and regularly evaluates student demographic information to ensure that it is honoring its mission. Your answers to the following questions, while voluntary, help us in this effort. Information you provide here will be kept confidential and will in no way influence a decision with regard to your application for admission.
Citizenship
*
U.S Citizen
Non- U.S. Citizen
Military Status
*
Active Duty
Veteran
Military Spouse or Dependent
Not Applicable
How did you hear about Lillie's Institute of Phlebotomy/EKG?
Who recommended Lillie's Institute of Phlebotomy/EKG to you?
Know anyone who is or was a Lillie's Institute of Phlebotomy/EKG student
Yes
No
Did any of your parents attend college?
Yes
No
Did any of your parents graduate college?
Yes
No
Marital Status
*
Divorced
Married
Separated
Single
Widowed
I would rather not answer
Ethnic Background
*
White
Black
Hispanic
Native American
Asian
Pacific Islander
Other
Are you Hispanic/Latino
*
Yes
No
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Signature
Signature
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Phlebotomy Course
$
675.00
Total
$
0.00
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