registration form 4595 Walnut Rd –Unit M PO Box 116, Buckeye Lake Oh 43008 Office 740-994-4301, Fax 740-205-0097 www.thetrainingcenter.info Student: ________________________________________________ Birth Date: _________________ Address: __________________________________________________________________________ Phone Number: ____________________________Alternate Phone: ___________________________ S.S. Number: _________________________ E-mail Address_________________________________ I am hereby enrolling in the following academic program and my enrollment is subject to the terms and conditions stated in this enrollment agreement. Program Name (check all that apply): STNA _________ Phlebotomy ________ EKG ________ Start Date: _________________________ Graduation date: ________________________ Final class percentage (To be filled out by instructor): __________________________________ Expected program length: STNA- 75 Clock Hrs. Phlebotomy- 80 Clock Hrs EKG- 50 Clock Hrs This program is normally completed within 3 calendar weeks (12 DAYS) Tuition and Fees: STNA Phlebotomy EKG Registration Fee… $75.00 Registration Fee... $120.00 Registration Fee...$100.00 Tuition………….... $480.00 Tuition…................$680.00 Tuition...............…$560.00 Maintenance fee…$70.00 Maintenance Fee...$70.00 Maintenance fees..$70.00 Total Cost….……. $625.00 Total Cost........…...$870.00 Total Cost………...$730.00 Tuition and fee charges are subject to change at the school’s discretion. Any tuition or fee increases will become effective for the school term following student notification of the increase. Cancellation and Settlement Policy This enrollment agreement may be cancelled within five calendar days after the date of signing provided that the school is notified of the cancellation in writing. If such cancellation is made, the school will refund in full all tuition and fees paid pursuant to the enrollment agreement and the refund shall be made no later than thirty days after cancellation. This provision shall not apply if the student has already started academic classes. Refund Policy If the student is not accepted into the training program, all monies paid by the student shall be refunded. There is one (1) academic term for this program. Refunds for tuition and refundable fees shall be made in accordance with following provisions as established by Ohio Administrative Code section 3332-1-10: (1) A student who withdraws before the first class and after the 5-day cancellation period shall be obligated for the registration fee. (2) A student who starts class and withdraws before the academic term is 15% completed (12 clock hours) will be obligated for 25% of the tuition and refundable fees plus the registration fee. (3) A student who starts class and withdraws after the academic term is 15% complete but before the academic term is 25% completed (20 clock hours) will be obligated for 50% of the tuition and refundable fees plus the registration fee. (4) A student who starts class and withdraws after the academic term is 25% complete but before the academic term is 40% completed (32 clock hours) will be obligated for 75% of the tuition and refundable fees plus the registration fee. (5) A student who starts class and withdraws after the academic term is 40% completed will not be entitled to a refund of the tuition and fees. The school shall make the appropriate refund within thirty days of the date the school is able to determine that a student has withdrawn or has been terminated from a program. Refunds shall be based upon the last date of a student’s attendance or participation in an academic school activity. Complaint or Grievance Procedure All student complaints should be first directed to the school personnel involved. If no resolution is forthcoming, a written complaint shall be submitted to the director of the school. Whether or not the problem or complaint has been resolved to his/her satisfaction by the school, the student may direct any problem or complaint to the Executive Director, State Board of Career Colleges and Schools, 30 East Broad Street, Suite 2481, Columbus, Ohio 43215, Phone 614-466-2752; toll free 877-275-4219. I acknowledge that I have received a school catalog and agree with the school policies and procedures as stated. I acknowledge that I have received and read a copy of this enrollment agreement. Applicant signature: _____________________________________date: __________________ Parent or Guardian (if applicable): __________________________date: __________________ School representative: Debra Ziadeh RN Requirements for STNA Class 1. Complete Enrollment Agreement & Tuition arrangements 2. Must be 16 years or older 3. Must have 2 step TB test completed prior to Clinicals 4. Complete the Ohio student disclosure course Requirements for Phlebotomy class 1. Must Have High School Diploma or GED 2. Must be a minimum of 16 yrs old. 3. Complete Enrollment Agreement & Tuition arrangements Requirements for EKG class 1. Must be at least 16 yrs. old 2. Have a high school diploma or GED, 3. Have a Phlebotomy Certification. 4. Complete Enrollment Agreement & Tuition arrangements Graduation Requirements: Complete all requested hours of class, skills and labs Pass total of all tests/exams with 75% for STNA and 70% for Phlebotomy and EKG or better Tuition paid in full Education Level: Less than high school ______ High School Graduate ______ GED ______ associate degree _____ Bachelor’s Degree _____ Master’s Degree _____ Master’s Plus_____ How did you hear about The Training Center? Employment Guide/Newspaper _____ Job Fair____ Facebook_____ Business cards/Flyers _____ Opportunity Links _____ Web site _____ Job & Family Services __________ Other__________________________________________ Check those that apply: ______SELF PAY (PAID IN FULL) ______PAYMENT PLAN (I understand that NO REFUNDS will be given with this plan) INITIAL ________ COMPANY/AGENCY/SPONSOR (*please attach documentation) __________ Company/Agency/Sponsor Name__________________________________________Authorized By________________________ Phone___________________ Address____________________________________ PO Box#_______ City_______________________________________State__________________Zip Code__________ ******Cannot sit for State Exam if any monies are owed******* (*Registration is incomplete without Company/Agency/Sponsor support documentation/ letterhead*) (Please make checks/money orders payable to The Training Center) I, the undersigned, understand that my enrollment is voluntary and that I shall not hold the school or its officials responsible for injury resulting from my action or conduct. In the event of an accident, I give my permission for the instructor or school official to contact the ambulance service and facilitate medical attention of my injuries in the necessary manner. Signature_____________________________________________Date___________________ Person to notify in case of emergency________________________________ Relationship__________ Phone_______________________________ Alternate Phone______________________________ ***I have recognized the placement statistics at the time of registration at The Training Center*** Applicant Signature______________________________ Date________________ |