Phlebotomy Tech Form

Hawaii Health Care Institute (The “LEI” of Hawaii)

PHLEBOTOMY TECHNICIAN COURSE email: [email protected]

__________________________________________________________________________________________ 305 Wailuku Drive, Suite 6 Tel: (808) 933-1295 Hilo, Hawaii 96720 Fax: (808) 933-2722

APPLICATION FORM Name: _______________________ Address: _____________________ _____________________

Social Security Number: ________________ Phone: (Home) ________________ (Cell) _______________ (Work) ______________

18 years age or older? US Citizen?

No No

Yes Yes

Green Card?

Yes

Have you ever been convicted of a crime or had traffic violation (s) by any court? Yes If Yes, please explain nature of the incident and current status on space provided below:

No No

_________________________________________________________________________________ _________________________________________________________________________________

If applicable, will you be able to provide letters from your probation officer? ______________ If applicable, will you be able to provide at least three (3) letters of recommendation? ______ Emergency Contact Person: Address:

___________________

Phone: ______________

__________________________ __________________________

How did you hear about Hawaii Health Care Institute? _______________________________ ♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦ Agency Sponsored? Yes No Contact Person ________________ ____________________

Name of Agency Phone Number

____________________

How did you hear about Hawaii Health Care Institute? _______________________________

Tuition Fee: $575.00 Fee: $150.00

Non Refundable Registration

STUDENT AGREEMENT I agree to release and hold harmless, Hawaii Health Care Institute, its staff and clients who provides my training and clinical practice from any accidents or misconduct that arises during the period of my training. I certify that all statements made here on this application are true to my knowledge.

_____________________________ Student’s Name (Printed) _____________________________ Signature _____________________________ Date

Hawaii Health Care Institute (The “LEI” of Hawaii)

PHLEBOTOMY TECHNICIAN COURSE email: [email protected]

__________________________________________________________________________________________ 305 Wailuku Drive, Suite 6 Tel: (808) 933-1295 Hilo, Hawaii 96720 Fax: (808) 933-2722

PHYSICAL EXAMINATION FORM Name: _______________________ Sex: F M Date of Birth: _____________ Address: ______________________ Phone: _____________ Cell _______________ ______________________ email: ________________ Any serious illness?

Yes

No

If YES, please explain _______________________________________________________ Any Surgery or Injury?

Yes

No

If YES, please explain _______________________________________________________ Have you received treatment or counseling for alcohol, drug related or emotional problems? Yes No If YES, please specify ____________________________ Do you have any type of handicap which limits function? _________________________ Are you able to lift fifty pounds?

Yes

No

Results of PPD Ist Step Results:

Date Taken: __________________ _____________

Date Read: _______________ Results: ______________

2nd Step Results:

Date Taken: __________________ _____________

Date Read: _______________ Results: _______________

Chest X-Ray if Positive PPD Date: _____________________ Attending Physician:

Results:

_________________________

_________________

Date: _______________

PHYSICAL EXAMINATION VERIFICATION (To be completed by Physician ) Significant Medical History pertinent to the student’s ability to participate in the Phlebotomy Technician Course: __________________________________________________________________________ Are there medications which may affect the student’s mental or physical performance? __________________________________________________________________________ Current complaints affecting the student’s ability in the Phlebotomy Technician Course? __________________________________________________________________________ I have examined _______________________________, and have found him/her not to have any communicable disease or any health condition that is hazardous to him/her self, patients, visitors or anybody. He/she is physically and emotionally fit for the Phlebotomy Technician Course and/or employment. ___________________________ Physician’s Name (Print) ___________________________ Physician’s Signature ___________________________ Date

I, ________________________, give permission to release this health information to Hawaii Health Care Institute. ____________________________ Student ____________________________ Signature ___________________________ Date