New BAMA Institute Enroll Now & Pay Form

BAMA Institute Enroll Now & Pay Form

First Name

Last Name

Contact Information

Street

Apartment/Unit Number

City

State/Province

Zip/Postcode

Cell Phone

Birth Date

Social Security No

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Is English your second language?

Yes No Not Selected

You must be fully vaccinated to enroll into this course. Please note that students for whom English is a second language will be required to pass a basic English test prior to their class start for admission into the Phlebotomy Technician or EKG Technician course.

Please also note we close registration on Thursday at Noon prior to the class start date for both weekend and weekday courses.

Program

Payment Plan

Default Payment Plan for Invoice

Schedule

Campus

Program Start Date

Scrub Size

Other Size

Scrub sizes are one size bigger and only come in one size sets. Once scrubs are opened you cannot return.

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Current Employment Status

Employment Type

Employer

Position

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Disability

Yes No

Disability Description

Learning Difficulties

Yes No

Learning Difficulties Description

Special Accommodations:

Please notify studentaffairs@bamasf.com if you require accommodations to complete your program.

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Have you ever been convicted of a felony?

Yes No Not Selected
Please note: Some felony convictions may exclude you from working in certain healthcare related enviroments.

If yes, please provide details.

While a felony conviction will not impact your admission to our programs, please note that having a criminal background may prohibit your employment efforts in the healthcare field. It is your responsibility to verify whether your criminal background will affect your chances of obtaining a California State License of Phlebotomy. Please ask an Admissions Representative for the appropriate contact information.

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BAMA Institute reserves the right to deny admission to any applicant who does not demonstrate the ability to benefit from the training program.

BAMA Institute does not discriminate on the basis of Race, Color, National Origin, Sex, Handicap, or Age in employment, admissions or any of its educational programs or activities.

Please note: There is a $100.00 non-refundable registration fee upon enrollment.

IF YOU ARE UNDER 18 YEARS OF AGE YOUR PARENT OR GUARDIAN MUST ALSO SIGN THIS APPLICATION.

The above information is true to the best of my knowledge

Yes No Not Selected

Applicant Signature

Parent/Guardian Signature

Payment Agreement

BAMA Institute, LLC will send you an Auto Charge form to complete. If the form is not completed by the 1st day of class, the full remaining tuition & fees will be due on the 1st day of class. This payment authorization is valid and will remain in effect unless I send written or email notification of its cancellation to finance@bamasf.com.

Receipts will be emailed to the billing system email addresses on file.

Payment Plans

Phlebotomy Program

Deposit: $500

Remaining Installments: 8 payments of $337.50 due every 2 weeks starting on the first day of class.

EKG Program

Deposit: $400

Remaining Installments: 4 payments of $292.50, due every 2 weeks starting on the first day of class.

Name of Payor (First & Last Name)

Name of Person Agreeing to Payment Plan

Payment Agreement Signature

Agrees to Payment Structure Upon Registration

Authorized Official Signature

Payment Information

Items	Amount
Tuition	$0.00
Total	$0.00

Payment Method

Required

First Name (as on card)

Same as applicant first name

Required

Last Name (as on card)

Same as applicant last name

Required

Address (as on card)

Same as applicant address

Required

City (as on card)

Same as applicant city

Required

State/Province (as on card)

Same as applicant state

Required

Zip (as on card)

Same as applicant zip

Required

Phone Number

Required

Credit Card Type

Required

Card Holder Name

Required

Card Holder ID / RIF

Required

Credit Card Number

Required

Expiration Date

Required

Security Code

Required

Currency

USD

Account Number

Required

Routing Number

Required

I understand that while attending student lab practice, I may be exposed to blood, body fluids, or tissues. I will use the appropriate personal protective equipment, including but not limited to gloves, gowns, and masks, as required when there is an inherent potential for mucous membrane or skin contact with blood, body fluids, or tissues, or when there is a potential for spills or splashes of them.

I understand that if I have a medical reason that prevents me from having my blood drawn during lab practice, I must email studentaffairs@bamasf.com at least 2 weeks prior to the class start date.