New Application/ Enrollment Agreement

Application/ Enrollment Agreement

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Please read all the information in the Student catalog/handbook and application carefully. Before filling out the application, the applicant is required to meet with the Director of Education and the Registrar to discuss the parameters of the program.

Campus

General Information

Application Date

First Name

Middle Name

Last Name

Gender

Day Phone

Home Phone

Cell Phone

Ethnicity

Birth Date

Street

City

State/Province

Zip/Postcode

Country

Previous Address

(If current address is less then one year complete previous address)

City

State

Zip

SSN

Citizen Type

Do you have a physical handicap/health conditions that would prevent you from working in the field of Medicine?

Yes No Not Selected

If yes, please explain

I will submit one of the following documents

(Please choose one)

Program

Emergency Contact

Please include Emergency Contact information.

Name

Address

Telephone

Relationship

High School Information

Medical Skills for Life Institute will attempt to contact your high school to obtain proof of your ability to benefit from the course I authorize Medical Skills for Life Institute to obtain a copy of my high school transcripts:

High School Diploma

Yes No Not Selected

GED

Yes No Not Selected

High School Diploma/Transcript

Name of High School Attended

Address

City

State

Zip

Phone Number

Fax Number

Graduation Date

Print name used while attending High School

Print present name if different

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By signing below student hereby authorizes the institution named above to release their academic transcripts to Medical Skills for Life Institute

Credit For Previous Training

Medical Assistant Program Information

Entry-level competencies for the medical assistant certificate program include, but are not limited to:

Administrative Medical Assistant: perform clerical functions of all aspects in the medical office, bookkeeping procedures, transcription, process Insurance claims and patient billing and collections

Clinical Medical Assistant: Perform patient Care techniques; administer medication, laboratory specimen collection, diagnostic procedures and all fundamental procedures of the back office

Phlebotomist/Laboratory Assistant: Draws blood collects laboratory specimens and Assist with Laboratory Procedures

Comments / Notes

Financial Aid Institution

Student will receive the provisions from the outside lending institution CREDIT FOR PREVIOUS TRAINING IS NON-APPLICABLE!

Name and Address of Financial Aid Institution

City, State, Zip

Phone Number

General Expectations

• All students are expected to appear neat, freshly clean, groomed and appropriately attired in the classroom, clinic and at all student functions and activities. Sloppiness, slovenliness, and lack of grooming are unacceptable.

• All students are expected to conduct themselves in an appropriate manner and demonstrate qualities reflecting a professional-in-training. These qualities include honesty, self-responsibility, consideration for others and mature judgment, common courtesy to others and be cooperative with faculty and staff.

• All students are expected to have a desire to become competent professionals and have a positive attitude toward the profession.

• All students are expected to participate in class discussions, class activities, (examples are participating in Mock Clinics and guest speaker lectures), public relations such as health fairs, and other activities which may occur outside traditional school week hours designated by the program administration that are beneficial to students.

• All students are expected to attend tutoring classes if academic grades fall below a ‘C’ average.

• All students eligible to graduate are expected to participate in graduation ceremonies.

• All students are expected to know and follow the policies in the catalog/student handbook.

General Expectations

(Please initial here)

Refund Policy

Right to cancellation: Students have the right to cancel this enrollment agreement for three days from the date of signing the agreement for any reason.
Process for Cancellation: Students may submit in writing a letter to cancel their enrollment within 3 days of enrollment to eli@medicalskillsforlife.com. Medical skills for life institute will return any monies paid by the student within 15 days of the request to cancel. Any funds paid by a third party on behalf of the student will be returned to the payee. Students who cancel after the three-day cancellation period are subject to the institutions refund policy.

Refund Policy

(Please initial here)

References

Examples of References(s)
List names, titles, addresses, phone numbers and e-mail addresses of three people that you will use as a reference. Preferably school teachers, present or former employer, peer person and one adult (other than parent or sibling).

First Reference Name

Title

Institution

Address

City

State

Zip Code

Phone

E-Mail Address

Second Reference Name

Title

Institution

Address

City

State

Zip Code

Phone

E-Mail Address

Third Reference Name

Title

Institution

Address

City

State

Zip Code

Phone

E-Mail Address

Enrollment Questionnaire

The enrollment questionnaire is intended to assist in the admission process. Our goal is to enroll students that characterize maturity, ambition and self-esteem.

1. Tell us something about yourself that would really surprise us?

2. Once you have successfully completed our program, what goals are you setting for yourself?

3. How will the community benefit from you becoming a Medical Assistant/Phlebotomist?

4. How will you benefit by becoming a Medical Assistant/Phlebotomist?

5. If given a choice to do volunteer work what would you choose to do and why?

6. If you had 15 minutes alone, with a very influential, political official, what message would you like him/her to take back to Washington?

7. Describe a person whom you admire and has had a positive influence in your life?

8.What was the admiration and how were you influenced?

9. What makes you the interesting person that you are?

10. Use one word to describe yourself?

11. Have you been convicted of a Felony or misdemeanor?

HOW DID YOU HEAR ABOUT US?

Enrollment Agreement

Student Name

This Enrollment agreement and Student Catalog/Handbook shall apply as a legally binding contract made between Student and Medical Skills for Life Institute

Agreement Date

Print Student Name

The person signing the enrollment agreement has received and read a copy of Catalog/Student handbook and the enrollment application, which will act as the binding document and understands all components, are part of the enrollment agreement.
I attest that I have read this agreement, and my signature is given below:

Signature

Date

School Officials Signature

Date

Director Signature

Date

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IMPORTANT: The student will be required to and agree to be governed by these policies for as long as he/she is enrolled

Medical Skills For Life Institute
2725 S Jones Blvd #108
Las Vegas, NV 89146
Telephone: (702) 645-7900

Statement Of General Health

Students Name

No Problems

Yes No Not Selected
To the best of my knowledge, I do not have any known physical or emotional problems that might negatively affect my progress in my educational program or participation in clinical or extern activities, both as a student and upon graduation.

If problems, please explain below

Student Signature

Date

DISABILITY SERVICES STUDENT INTAKE FORM

This form is to be completed by the student only. If the student requires assistance, please seek the help of one of the Directors of Medical Skills for Life (Eligah Nesmith or Valerie Nesmith), your student ombudsman, or your Faculty ombudsman. Fill out the form as completely as you can, and provide the required documentation as soon as possible. All information is confidential

Declared Disability(ies)

Describe how your disability affects your performance as a student (Feel free to add additional pages, if needed)

History of Accommodation (Please list whether and how you have previously been accommodated by an educational institution for your disability or disabilities, if applicable. A lack of prior accommodation is not disqualifying of accommodation)

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Required Documentation: You are required to present a recent letter, on official letterhead from a pertinent professional, containing a clear statement regarding your disability, and/or need for accommodation. You should do so as quickly as possible. Failure to provide adequate or appropriate documentation within a reasonable time to substantiate your disability and/or need for an accommodation, any accommodation granted to you may be removed. My signature below affirms that I am seeking a reasonable accommodation of my disability (or disabilities) as a student at Medical Skills for Life, and for no other purpose. I attest that every part of this application is true, and that any documentation that I present in support of this application is true, to the best of my knowledge and belief. By signing below, I understand that despite my disability, I must meet the minimum standards as set forth by my program of study and the classes I take with or without accommodations; I am responsible for following the school’s policies and code of conduct found in the school and online. I also understand that it is my responsibility to communicate with my instructor concerning my accommodation(s), where necessary or called for, to help ensure that there are no gaps in my instruction, and that I am being accommodated, where appropriate. I acknowledge that as a student it is my responsibility to let my instructor and/or the Directors of Medical Skills for Life know if I have any concerns or problems with my accommodation.

Student Signature

Acceptance of form by: (Name & Title)

Assessment Of Ability To Benefit

High School Level

(Please check one)

Program

Referred By

ASSESSMENTS: (Provided by student)
Physical Condition:

List any physical limitations that may hinder successful completion of course work and subsequent employment in chosen field.

Marketable Skills:

List prior experience or education that will aid the student in his/her chosen field.

Remedial Requirements

State specific areas of deficiency requiring remedial work

Remedial Action

List the courses and specific level of competency to be attained and required by date of completion.

Comments

Student Signature

Date

Admissions Representative Signature

Date

Friends Helping Friends

Our school’s “Friends Helping Friends” program is designed for our students who care about helping their friends or relatives who may:

1. Not be satisfied with their current job
2. Have no opportunity for advancement
3. No longer be able to work in their current job
4 .Not be earning enough money

Name

I would like the following individuals to receive career training information from our school

1. Name

Address

City

State

Zip

Relationship

Cell Phone

Home Phone

Work Phone

Email address

2. Name

Address

City

State

Zip

Relationship

Cell Phone

Home Phone

Work Phone

Email address

3. Name

Address

City

State

Zip

Relationship

Cell Phone

Home Phone

Work Phone

Email address

Signature

Student Signature

Date