New Enroll & Pay

Enroll & Pay

First Name

Last Name

Contact Information

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

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:

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Have you ever been convicted of a serious crime (felony)?

Yes No Not Selected

If yes, please provide details.

Please be reminded 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 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)

Required

City (as on card)

Required

State/Province (as on card)

Required

zip (as on card)

Required

Phone Number

Required

Credit Card Type

Required

CardHolder Name

Required

CardHolderID / 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, required when there is an inherent potential for mucous membrane or skin contact with blood, body fluids or tissues, or a potential for spills or splashes of them.