ENROLLMENT AGREEMENT

fall term 2021

COURSE:

TERM:

CRN:

INSTRUCTOR:

PHLEBOTOMY

FALL 2021

B

ROB CERNA

M, T, TH

6:00 PM - 9:00 PM

960 SW Disk Dr. #102

DATE:

DAYS:

CLASS TIME:

LOCATION:

COURSE DESCRIPTION:

This course is designed to provide basic knowledge and skills necessary to perform venipuncture (phlebotomy) in a clinical setting. In addition, this course will prepare students to obtain phlebotomy certification from the National Healthcareer Association (NHA). Students will receive instructions on anatomy and physiology, regulatory and ethical issues, safety and infection control, blood collection equipment, and venipuncture procedures. Students will be guided to engage in venipuncture procedures that are performed under the guidance of instructors using a variety of prosthetic devices. Students are required to be participants, providers, and receivers of phlebotomy (unless a medical note is provided).

Required Student Information in accordance with OAR 715-045-0018

Read the requirements and then fill in the information needed below:

a) To ensure enrollment can be processed, all information must be completed fully; if a student does not fill in the necessary information, the school has the right to reject the application

b) Do not use a school email address; use only a personal email address. If the student does not have one, please take the time to create one beforehand

c) If a student refuses to release his or her Social Security Number, the school may assign an alternative identification number

d) TERMS OF CONTRACT – Student Loan (ORS 345.113)

U.S. Citizen
OR Resident
Disabled
Veteran
Gender
Ethnicity / Race

COST BREAKDOWN

Registration Fee:

Supply Fee:

Set-Up Fee (Optional):

Tuition Cost:

$150.00

$100.00

$25.00

$2,250.00

 

TOTAL = $2,500.00

*25.00 set-up fee for Payment Plan 3

Terms of Installment Payment Plan:

  • Choose one by applying a check mark (✔)

  • If you do not choose a payment plan, you will be selected for Payment Plan 1 by default

  • If the payment is not received within 5 days of the due date, a $59.00 late fee will be applied

  • Thereafter, any unpaid balance will accrue an additional 10% late fee per month

Payment Plans

Cancellation and Refund Policies (OAR 715-045-0036)

A student may cancel enrollment by giving written notice to the school. Unless the school has discontinued the program of instruction, the student is financially obligated to the school according to the following:

  • If cancellation occurs within five business days of the date of enrollment, and before the commencement of classes, all monies specific to the enrollment agreement shall be refunded;

  • If cancellation occurs after five business days of the date of enrollment, and before the commencement of classes, the school may retain only the published registration fee. Such fee shall not exceed 15 percent of the tuition cost, or $150, whichever is less;

  • If withdrawal or termination occurs after the commencement of classes and before completion of 50 percent of the contracted instruction program, the student shall be charged according to the published class schedule. The student shall be entitled to a pro rata refund of the tuition when the amount paid exceeds the charges owed to the school. In addition to the pro- rated tuition, the school may retain the registration fee, supply fee, $25 withdrawal fee, and other legitimate charges owed by the student.

  • If withdrawal or termination occurs after the completion of 50 percent or more of the program, the student shall be obligated for the tuition charged for the entire program and shall not be entitled to any refund;

  • The enrollment agreement shall be signed by both the student and the authorized school official. For cancellation of the enrollment agreement referenced in (a) & (b), the “date of enrollment” will be the date that the enrollment agreement is signed by both the student and the school official, whichever is later.

 

Any inquiry a student may have regarding this contract may be made in writing to Oregon Medical Training, PCS, 1126 Gateway Loop, Suite 108, Springfield, OR 97477 or to the Superintendent of Public Instruction, Oregon Higher Education Coordinating Commission, 255 Capitol St. NE, Salem, OR 97310 or by calling (503) 947-5751.

I have read and received a copy of the enrollment agreement as required in OAR 715-045-0018 (1) (a-d). I have also read and received a copy of the following:

 

(Initial) I have read the Student Catalog (The link is available on our website).

(Initial) I understand that I will receive and be required to sign a Release and Waiver of Liability the first day of class.

(Initial) I understand that I need to purchase the required book and have it for the first day.

 

Additionally, I understand the following:

After failure to attend class the first week, the school will attempt to contact the student via email and phone. It will then become the student’s responsibility to provide written notice to the school to cancel enrollment. If a registered student is absent from every day of class and has failed to notify Oregon Medical Training, PCS of the intended withdrawal after completion of 50 percent or more of the program, the student will forfeit registration, supply fee (if given supplies) and 50 percent tuition.

 

  • The tuition charges will accrue based on hours that the program is offered by the school and that I have contracted/scheduled to attend, rather than my actual attendance;

  • That any refund calculation is based on my last date of physical attendance; and;

  • Per OAR 715-0045-0008, Advanced Deposits, “Prior to the beginning of classes, no private career school shall require from an enrollee an advance deposit in excess of twenty (20) percent of the total tuition and fees:

 

    • Schools that offer short-term programs designed to be completed in one (1) term or four (4) months, whichever is less, can require payment of all tuition and fees on the first day instruction begins;

    • For those programs designed to be four (4) months or longer, a school cannot require more than one (1) term or four (4) months of advanced payment of tuition at a time. When fifty (50) percent of the program has been offered, the school can require payment of all tuition;

    • This limitation shall not apply to federal and state financial aid payments received by the school; and

    • At the student’s option, a school may accept payment in full for tuition and fees after the student has been accepted and enrolled and the date for commencement of classes is specifically disclosed on the enrollment agreement.”

 

MY SIGNATURE INDICATES THAT I HAVE RECEIVED THESE DOCUMENTS AND AGREE TO ANY STIPULATIONS LISTED IN THEM.

Upload BOTH documents:

RequiredDriver's License

Optional: State Issued ID, Birth Certificate, Passport

Required: High School Diploma

Optional: HS Transcript, GED Certificate

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