New Student Application

General Information

Application Date	(Required)
Campus
First Name
Middle Name
Last Name
Gender	Male Female
Day Phone	(Required)
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
Email
SSN	(Required)
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	(Required)

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

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

Signature

Student Signature	(Required)
Date	(Required)

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

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

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
3110 S Rainbow Blvd
Suite #104
Las Vegas, NV 89146
Telephone: (702) 645-7900

Financial Aid Institution

Name and Address of Financial Aid Institution
City, State, Zip
Phone Number

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

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

(Required)
(Please initial here)

Refund Policy

NRS 394.449 Requirements of policy for refunds by institutions:

1. Each postsecondary educational institution shall have a policy for refunds, which at least provides:
(a) That if the institution has substantially failed to furnish the training program agreed upon in the enrollment agreement, the institution shall refund to a student all the money he has paid.
(b) That if a student cancels his enrollment before the start of the training program, the institution shall refund to the student all the money he has paid, minus 10 percent of the tuition agreed upon in the enrollment agreement or $100, whichever is less.
(c) That if a student withdraws or is expelled by the institution after the start of the training program and before the completion of more than 60 percent of the program, the institution shall refund to the student a pro rata amount of the tuition agreed upon in the enrollment agreement, minus 10 percent of the tuition agreed upon in the enrollment agreement or $100, whichever is less.
(d) That if a student withdraws or is expelled by the institution after completion of more than 60 percent of the training program, the institution is not required to refund the student any money and may charge the student the entire cost of the tuition agreed upon in the enrollment agreement.

2. If a refund is owed pursuant to subsection 1, the institution shall pay the refund to the person or entity who paid the tuition within 15 calendar days after the:
(a) Date of cancellation by a student of his enrollment;
(b) Date of termination by the institution of the enrollment of a student;
(c) Last day of an authorized leave of absence if a student fails to return after the period of authorized absence; or
(d) Last day of attendance of a student, whichever is applicable.

3. Books, educational supplies or equipment for individual use are not included in the policy for refund required by subsection 1, and a separate refund must be paid by the institution to the student if those items were not used by the student. Disputes must be resolved by the Administrator for refunds required by this subsection on a case-by-case basis.

4. for the purposes of this section:
(a) The period of a student’s attendance must be measured from the first day of instruction as set forth in the enrollment agreement through the student’s last day of actual attendance, regardless of absences.
(b) The period of time for a training program is the period set forth in the enrollment agreement.
(c) Tuition must be calculated using the tuition and fees set forth in the enrollment agreement and do not include books, educational supplies, or equipment that is listed separately from the tuition and fees.

Refund Policy

(Required)
(Please initial here)

Statement Of General Health

Students Name	(Required)
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	(Required)

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

Assessment Of Ability To Benefit

High School Level	9 10 11 12 (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	(Required)
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

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?	(Required)
2. Once you have successfully completed our program, what goals are you setting for yourself?	(Required)
3. How will the community benefit from you becoming a Medical Assistant/Phlebotomist?	(Required)
4. How will you benefit by becoming a Medical Assistant/Phlebotomist?	(Required)
5. If given a choice to do volunteer work what would you choose to do and why?	(Required)
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?	(Required)
7. Describe a person whom you admire and has had a positive influence in your life?	(Required)
8.What was the admiration and how were you influenced?	(Required)
9. What makes you the interesting person that you are?	(Required)
10. Use one word to describe yourself?	(Required)
11. Have you been convicted of a Felony or misdemeanor?	(Required)
HOW DID YOU HEAR ABOUT US?	(Required)


Enter the above code	Required