Nursing Education Training Programs Institutional Catalog

1

Nursing Education Training Programs

Institutional Catalog

Cleveland-304 A 20th Street SE Cleveland, TN 37311 423-472-1595

Johnson City-2203 McKinley Road-Suite 219 Johnson City TN 37604 423-928-3561

Knoxville-6921 Middlebrook Pike Knoxville, TN 37909 865-584-2999

Lawrenceburg-181 Prosser Road PO Box 61 Lawrenceburg TN 38464 931-762-1599

Maryville-1741 Triangle Park Drive Maryville, TN 37801 865-983-0821

Nashville-2201 Charlotte Avenue Nashville TN 37203

615-250-4300

www.redcross.org

Table of Contents

History Page 3

Purpose Page 3

Learning Objectives Page 3

Program Objectives Pages 4, 5

Instruction Methodology Page 4

Authorization Page 5

Grievance Procedures Page 5

Board of Directors Page 6

Nurse Aide Training Faculty Page 6

Admission Requirements Pages 6, 7

Class Schedule/ School Holidays Page 7

Tuition/ Additional Expenses Pages 7, 8, 9

Refund Policy Page 9

Completion Requirements Page 9

Explanation of Student Progress Page 9

Job Placement Assistance Page 10

Credit Granted Page 10

Transferability of Credits Page 11

Student Code of Conduct Page 12

Consequences of Unacceptable Behavior Page 13

Enrollment Agreement Page 14

3

HISTORY

The American Red Cross is a private, non-profit organization dedicated to helping people prevent, prepare for, and respond to emergencies. The Red Cross is not a government agency and does not receive government funds. The American Red Cross relies on the support of the American people to carry out its lifesaving mission

The American Red Cross has been involved in nursing for more than 100 years, and our Nursing Education Training courses continue the American Red Cross tradition of outstanding training that benefits participants and their

communities.

American Red Cross Nursing Education Training Programs are authorized by the Tennessee Higher Education Commission. This authorization must be renewed each year and is based on an evaluation by minimum standards concerning quality of education, ethical business practices, health and safety, and fiscal responsibility.

American Red Cross Nurse Aide Training Programs are approved by the Tennessee Department of Health and that approval is required every 2 years based on an evaluation of minimum standards. American Red Cross Phlebotomy Technician, EKG Technician and Patient Care Technician training programs are nationally certified by the National Healthcareer Association.

PURPOSE & LEARNING OBJECTIVES

The purpose of American Red Cross Nursing Education Training courses is to provide the information and skills that will enable graduates to provide quality and compassionate care in long-term care facilities, hospitals, assisted living facilities, home health/hospice agencies, medical offices, and private duty agencies.

With Red Cross training, students master fundamental academic and social skills necessary to be successful in the healthcare industry. American Red Cross students not only excel academically, but also gain self-esteem and independence. And as an American Red Cross trained graduate, you’ll be an important part of a health care team that works together to provide compassionate care for residents and patients in health care facilities. It’s a job where you can make a difference.

The American Red Cross courses provide:  Hands-on, real life experience  Instructor attention

 Learning at a comfortable pace  Knowledge and confidence

 Skills to secure part-time or full-time employment

TRAINING PROGRAM OBJECTIVES

 Student will recognize the importance of the nurse assistant’s role in improving the quality of life for people in the health care system

 Student will understand the importance of encouraging patients/residents to be as independent as possible

 Student will understand the importance of supporting and maintaining the rights of residents, clients and patients

 Student will learn and understand the importance of the healthcare worker’s sensitivity to the physical and psychosocial needs of people in the health care system.

 Student will understand the importance of clear and precise communication  Student will understand and apply basic Medical Ethics

Students taking this 120 hour course will learn the basic principles of care, infection control and the

importance of maintaining HIPAA. After successful completion of this course the student is then eligible to sit for the Tennessee State Nurse Aide Examination. Tuition - 1250.00

PHLEBOTOMY TECHNICIAN-KNOXVILLE

 Student will understand basic medical laws relating to Phlebotomy  Student will understand the importance of medical ethics

 Student will understand quality control

 Student will develop an understanding of medical terminology and its use  Student will use and understand correct medical terminology

 Student will understand the importance of excellent customer service in the healthcare setting.  Student will understand basic human anatomy and physiology

 Student will become proficient in blood drawing skills and specimen collection

 Student will learn procedures for transportation, handling and processing of specimens.

 Student will learn how to prevent the spread of Bloodborne pathogens, and the importance of infection control.

 Student will understand and apply HIPAA guidelines

 Student will understand the importance of patient interaction.  Student will pass the national certification exam

Students taking this 88 hour classroom course, will learn basic anatomy and physiology, Bloodborne pathogen standards, infection control and technical blood draw skills. After completion of the classroom portion of this course, the student is assigned a clinical site and is required to complete an approximate 2 week clinical rotation. After completion of the rotation, student is eligible to sit for the National Healthcareer Association Certified Phlebotomy Technician examination. Tuition - 1495.00

EKG TECHNICIAN-KNOXVILLE

 Student will understand specific cardiac anatomy and normal cardiac function  Student will understand the importance of medical Ethics

 Student will learn how to use diagnostic 6 and 12 lead EKG machines  Student will understand quality control

 Student will learn to recognize life threatening cardiac arrhythmias  Student will develop an understanding of medical terminology and its use

 Student will understand the importance of excellent customer Service in the healthcare setting.

 Student will understand and use universal precautions to prevent the spread of Bloodborne Pathogens and to encourage Infection Control in the healthcare setting

 Student will understand and apply HIPAA Guidelines

 Student will pass National Certification Exam with an exam score of 70% or better.

Students taking this 80 hour course will learn cardiac anatomy specific to the heart, medical ethics and medical terminology. After completion of the classroom portion of this course, the student is assigned a clinical site and is required to complete an approximate 2 week clinical rotation. After completion of the rotation, student is eligible to sit for the National Healthcareer Association Certified EKG Technician examination. Tuition - 995.00

PATIENT CARE TECHNICIAN-KNOXVILLE

Students who hold a current CNA Certification, a current NHA Phlebotomy Technician Certification and a current NHA EKG Technician Certification are eligible to sit for the Patient Care Technician Certification exam. 200.00

5

INSTRUCTION METHODOLOGY

Students are assigned and expected to read the unit material that is being taught the next day. Instruction is given by lecture, discussion, demonstration and videos. At any time a student is free to ask questions to clarify information. At the end of the lecture/instruction or the next day, students are given a written test and if skills are included in the unit, each student must demonstrate mastery of that skill. Re-teaching takes place after the written test is checked and during skill demonstrations for mastery.

AUTHORIZATION

American Red Cross Training Programs are authorized by the Tennessee Higher Education Commission. This authorization must be renewed each year and is based on an evaluation by minimum standards concerning quality of education, ethical business practices, health and safety, and fiscal responsibility.

American Red Cross Nurse Aide Training Programs are approved by the Tennessee Department of Health. Approval is required every 2 years based on an evaluation of minimum standards..

American Red Cross Phlebotomy Technician, EKG Technician, and Patient Care Technician are approved by the National Healthcareer Association.

GRIEVANCE PROCEDURES

If any student feels that disciplinary action against them was unwarranted or the severity unfair, they must first appeal to the Instructor. If they are not satisfied with the response given them they may appeal to the Institutional Director. Any grievances that are not resolved on the institutional level may be forwarded to the Tennessee Higher Education Commission, Nashville TN 37243-0830 (615-741-5293)

BOARD OF DIRECTORS

TENNESSEE TRAINING FACULTY

Gail Bender, Admin. II, PHSS TN Territory

Melissa Brogger, RN, BSN, Lead Instructor - Knoxville

Samantha Stout, RN, Lead Instructor, Institutional Director - Maryville Glenda Bobalik, Institutional Director-Johnson City

Ginny Benson, Institutional Director-Lawrenceburg Joseph Simpson, Institutional Director-Nashville Julia Wright, Institutional Director-Cleveland Holly Blankenship, RN, BSN, Instructor - Knoxville Carol Cottick, RN, Instructor - Knoxville

Theresa Johnston, RN, BS Health Ed., Instructor - Knoxville Darlene Lemnah, RN, Instructor – Johnson City

Jamie Hornyak, LPN, Instructor – Nashville Connie Green, LPN, Instructor - Nashville

Sabrina Johnson, LPN, Instructor - Lawrenceburg Ronita Vanderford, LPN, Instructor - Lawrenceburg

ADMISSION REQUIREMENTS

Students must be 18 years of age or older to be admitted to the program. The American Red Cross uses the Asset Testing Program and all potential students must achieve the following scores to be admitted into the program.

Passing Scores: The approved passing scores on this test are as follows: Reading (32), Writing (32), and Numerical (32).

HOW TO APPLY

Interview sessions are conducted at the American Red Cross one or two days each week depending on the facility location. Applicants should call the chapter phone number listed on the front of the catalog to schedule an appointment. Applicants should be prepared to stay approximately 3.5 hours and all applicants must be prepared to take an entrance exam.

Prospective students are required to bring to the interview session: a completed application, a criminal background check, their driver‟s license or a valid photo ID and their social security card. Students applying for Phlebotomy, EKG or Patient Care Technician are required to bring a high school diploma to the interview session.

Some offenses listed on the background check could prevent a student from gaining employment in the health care field and will also prevent enrollment in American Red Cross Nursing Education Programs. No student will be admitted with a felony conviction or with charges that are pending. Misdemeanor offenses such as theft, assault, and other offenses may also prevent the enrollment of a potential student. The American Red Cross reserves the right to deny enrollment to a student if, in its sole judgment, the charge would prevent a graduate from gaining a position in the health care industry.

COMPLETION REQUIREMENTS

 Attend and participate in all course sessions

 Demonstrate competency in all required skills in the skills practice sessions and clinical practicum  Participate in all skills sessions

 Pass the final written exam and have an overall class average of 80 percent or better

 Pass the final skill exam with 80 percent or better on each skill without missing any bolded steps  Complete the clinical component of the course. STUDENT CANNOT MISS ANY CLINICAL TIME

CLASS SCHEDULE

Class Holidays

MLK

President‟s Day

Memorial Day

Independence Day

Labor Day

Thanksgiving + day after

Christmas

7

FACILITY LOCATION AND DESCRIPTION

Classroom Location: American Red Cross - Various Locations

Facility Description: Classes are held in the nursing laboratory and classroom. The lab is equipped with audio/visual equipment including projector, computer, DVD player and medical equipment including hospital beds, manikins, wheelchairs and various other items conductive to a hospital/nursing home setting

TUITION

Tuition is due prior to the first day of class. American Red Cross cannot accept cash for this course but does accept credit/debit cards, money orders, or cashier‟s checks. Money order/cashier‟s check should be made payable to: American Red Cross.

Tuition Includes:

 All classroom and clinical instruction  Textbook, workbook and class materials  Blood Pressure Cuff

 Stethoscope

 Water Resistant Watch with second hand

 American Red Cross CPR/Automated External Defibrillator (AED) Certification  American Red Cross First Aid Certification

 American Red Cross Nursing Assistant Pin upon Graduation  Initial state testing fee

 Patient Care Kit/Supplies

Additional Estimated Costs not included in tuition. This is only an estimate. Actual costs may vary.

Scrubs/Uniform

$30.00

Clinical Shoes

$50.00

TB Skin Test

$10.00

Physical Exams Varies

Phlebotomy Technician Training: $1495.00 (Knoxville)

Tuition is due prior to the first day of class. American Red Cross cannot accept cash for this course but does accept credit/debit cards, money orders, or cashier‟s checks. Money order/cashier‟s check should be made payable to: American Red Cross.

NOTE: The prerequisite for this course is a current „hands on‟ certification such as CNA, MA, EMT, etc. Tuition Includes:

 All classroom and clinical instruction  Textbook, workbook and class materials

 American Red Cross CPR for the Professional Responder Certification  American Red Cross First Aid Certification

 Bloodborne Pathogen Certification

 American Red Cross Phlebotomy Technician Pin upon Graduation  National testing fee-first time only

Additional Estimated Costs not included in tuition. This is only an estimate. Actual costs may vary.

Scrubs/Uniform $30.00

Clinical Shoes $50.00

Student Liability Insurance $35.00 (approximate) *

*Note: Student should seek advice from Instructor regarding monetary coverage limits before purchasing.

EKG Technician Training: $995.00 (Knoxville)

Tuition is due prior to the first day of class. American Red Cross cannot accept cash for this course but does accept credit/debit cards, money orders, or cashier‟s checks. Money orders/cashier‟s check should be made payable to: American Red Cross.

NOTE: The prerequisite for this course is a current „hands on‟ certification such as CNA, MA, EMT, etc. Tuition Includes:

 All classroom and clinical instruction  Textbook, workbook and class materials

 American Red Cross CPR for the Professional Responder Certification  American Red Cross First Aid Certification

 Bloodborne Pathogen Certification

 American Red Cross EKG Technician Pin upon Graduation  National testing fee-first time only

Additional Estimated Costs not included in tuition. This is only an estimate. Actual costs may vary.

Scrubs/Uniform $30.00

Clinical Shoes $50.00

Student Liability Insurance $35.00 (approximate) *

*Note: Student should seek advice from Instructor regarding monetary coverage limits before purchasing.

Patient Care Technician $3200.00 Tuition Includes:

 All classroom and clinical instruction for Nurse Assistant, EKG Technician and Phlebotomy Technician courses as well as state/national exam scheduling (one time only) for all. (Multi Course Discount)

Tuition is due prior to the first day of class. American Red Cross cannot accept cash for this course but does accept credit/debit cards, money orders, or cashier‟s checks. This tuition reflects bundle discounts. Money orders/cashier‟s check should be made payable to: American Red Cross.

REFUND POLICY

A full refund of all fees will be given if the classes are canceled or the student withdraws prior to the first day of class less an administrative fee of one hundred dollars ($100.00)

A partial refund will be given as follows:

75% refund if a student withdraws within the first 10% of scheduled class hours less an administrative fee of one hundred dollars ($100.00).

50% refund if the student withdraws within the first 20% of scheduled classes hours less an administrative fee of ($100.00).

9

No refunds are permitted after the first 20% of scheduled class hours.

A student is considered to have withdrawn when the student misses a total of 6 or more consecutive hours of class with no contact.

COMPLETION REQUIREMENTS

 Demonstrate competency in all required skills in the skills practice sessions and clinical practicum  Participate in all skills sessions

 Pass the final written exam and have an overall class average of 80 percent or better

 Pass the final skill exam with 80 percent or better on each skill without missing any bolded steps  Complete the clinical component of the course. STUDENT CANNOT MISS ANY CLINICAL TIME

EXPLANATION OF STUDENT PROGRESS & READMISSION

Due to the short nature of the course, student progress reports are made available to the student upon request. If a student doesn‟t make satisfactory progress, the instructor will individually meet with the student as soon as possible. The instructor will present the student with a written report stating the specific issues and what is needed to resolve them. Instructor will provide a copy to the student.

A student withdrawing in good standing can return within one year from their original start date to finish their specific course. If the student again withdraws, that student would be considered a new applicant. Student cannot transfer re-enrollment privilege to anyone for any reason.

JOB PLACEMENT ASSISTANCE

During the 5 week training program, prospective employers will speak with the class to present employment opportunities and answer students‟ questions. Prospective employers view this as an opportunity to recruit quality staff. In addition the American Red Cross Nursing Staff proactively seeks employment opportunities for certified graduates.

CREDIT GRANTED

Transferability of Credit Statement

Credits earned at the American Red Cross may not transfer to another

educational institution. Credits earned at another educational institution may

not be accepted by the American Red Cross. You should obtain

confirmation that the American Red Cross will accept any credits you have

earned at another educational institution before you execute an enrollment

contract or agreement. You should also contact any educational institutions

that you may want to transfer credits earned at the American Red Cross to

determine if such institutions will accept credits earned at the American Red

Cross prior to executing an enrollment contract or agreement. The ability to

transfer credits from the American Red Cross to another educational

institution may be very limited. Your credits may not transfer and you may

have to repeat courses previously taken at the American Red Cross if you

enroll in another educational institution. You should never assume that

credits will transfer to or from any educational institution. It is highly

recommended and you are advised to make certain that you know the

transfer or credit policy of the American Red Cross and of any other

educational institutions you may in the future want to transfer the credits

earned at the American Red Cross before you execute an enrollment

contract or agreement.

I have read and understand the above information.

____________________________________________________________________________

11

STUDENT CODE OF CONDUCT

The American Red Cross endorses a safe, secure, and positive learning environment. To successfully achieve this standard, the following rules of conduct have been established:

 No Cell Phones or electronic devices are allowed in the building. The first violation will result in forfeiture of the device for the rest of the class period. The second violation will result in termination. Each Instructor will provide the student with an emergency number for the student to be reached.

 Students will attend all classes on time. Students who are absent for more than one complete day of class time will be dropped from the course and will forfeit their payments to date.

 Students may not miss ANY clinical time.

 Students will be prepared for class with the appropriate materials and homework completed. Students will not participate in cheating or plagiarizing their work or the work of others.

 Students will be honest with all staff and students.

 Students will participate in positive group activities and will not be involved in any bullying, intimidating or harassing of staff or students.

 Students will show respect for others by not participating in teasing and ridiculing.

 Students will wear clean, neat, well-fitting and presentable clothing. Students will show respect for others by not wearing clothing with inappropriate messages (i.e. profane language, racial or sexual references, references to alcohol/illegal drugs or gang related).

 Students will respect the personal property of others and of the chapter.

 Students are responsible for any chapter textbooks, reference books, name tags, or equipment loaned to or used by them. If misused or damaged, students will be responsible for charges to repair or replace. If repayment is not received, students will not receive their NAT certification, and will forfeit their payments to date.

 Students must respect classmates, program guests, volunteer staff, etc. that choose to volunteer as patients. Students also agree that information entrusted to them by anyone on American Red Cross property or as a representative of the American Red Cross, will be treated with the utmost confidentiality and will not be discussed outside the Red Cross classroom setting.

 Students will respect and follow direction from all staff of the chapter. Students are expected to treat the instructor, staff and fellow students with respect at all times.

 Students will respect the safety of others by not bringing real or imitation weapons to the chapter.

 The American Red Cross has a zero tolerance policy for any student involved in or encouraging the involvement of another student in fighting or use of other physical force.

 American Red Cross forbids smoking in areas other than designated smoking areas.

 Neither alcohol nor illegal drugs are permitted. Students may not be under the influence of illegal drugs or alcohol at any time while on American Red Cross property, at a clinical site assigned to them or while representing the American Red Cross in any capacity. Any student observed to be displaying behavior which is observed to be decidedly different from behavior normally displayed by that student may be required to submit the appropriate specimen (urine or blood) for laboratory testing.

 Any student arrested, or found to be in violation of any law while enrolled must submit a hand written explanation of the incident to their Instructor within 48 hours of the incident. Disciplinary action may be taken. Students not submitting a written explanation or submitting a dishonest explanation of the incident will be immediately dismissed from the program and will not be allowed to return.

 All students will be issued an American Red Cross identification badge. Students must never allow anyone else to use their badge under any circumstances, and are responsible for its use/misuse. Students must wear their badge when in the building. Student must turn in their badge at graduation in order to receive diploma and be registered for state testing.

 FOR YOUR PROTECTION AND THE PROTECTION OF YOUR CLASSMATES: Video cameras may be installed in common areas of the American Red Cross building. Unregistered guests/guests without ID badges are not allowed at any time, and anyone requesting to see a student during school hours must check in with receptionist and receptionist will call the student to speak with the guest. For safety reasons, this is a chapter policy adhered to by all chapter staff and volunteers as well, and is expected to be adhered to by all visitors of the chapter.

CONSEQUENCES OF UNACCEPTABLE BEHAVIOR

Unacceptable behavior and violation of the Code of Conduct could result in dismissal from classes for the day or from the program. The decision of the Instructor/ Institutional Director shall be final. The instructor will provide to the student within one (1) week of any such dismissal a written statement for the reasons for the dismissal. Refer to the refund policy for a refund of funds, if applicable

RELEASE OF INFORMATION

_________ I understand that by initialing this paragraph, I give American Red Cross staff permission to release information to my sponsoring agency, employer, potential employer, or other persons or companies regarding my attendance, attitude, behavior, work habits and grades when requested and I release the American Red Cross and its staff from any liability that may result from the release of this information. American Red Cross will not forward HIPAA protected documents for any reason.

13

Pre-Enrollment Checklist

NOTE: To be filed once they have signed and dated this form.

Registration Date: ____________________

Name of School: American Red Cross

Name of Student: ____________________

Social Security Number: ____________________

Address: ____________________

City, State, Zip: ____________________

Telephone Number: ____________________

Name of program: (CIRCLE) NURSE ASSISTANT PHLEBOTOMY TECHNICIAN

EKG TECHNICIAN PATIENT CARE TECHNICIAN (TEST ONLY)

Please check mark below each section when completed

 Toured the institution

 Received an institutional catalog

 Was given the time and opportunity to review the institutional policies in the catalog

 Knows the length of the program for full-time and part-time students in the academic and

actual calendar time

 Has been informed of the total tuition and fee costs of the program

 Has been informed of the estimated cost of books and any required equipment purchase such

as stenography machine, computer, specialized tools, are supplies, etc.

 Has been given a copy of the institutional cancellation and refund policy



Understands what “transferability of credits” means and the specific limitations (if any) should

the institution have articulation agreements.

 Student has been informed that any grievances not resolved on the institutional level may be

forwarded to the Tennessee Higher Education Commission. Nashville TN 37243-0830.

(615)741-5293.

Instructor ____________________ Date __________

Student ____________________ Date __________

ENROLLMENT AGREEMENT

NURSING EDUCATION TRAINING PROGRAM

AMERICAN RED CROSS

ADDRESS:______________________________________________________________________________ CITY, STATE AND ZIP:____________________________________________________________________

American Red Cross Training Programs meet all state and federal requirements. This program is authorized

by the Tennessee Higher Education Commission. This authorization must be renewed each year and is based

on an evaluation by minimum standards concerning quality of education, ethical business practices, health and

safety and fiscal responsibility.

American Red Cross courses are full-time. Through lecture, video, role-playing, and hands-on laboratory and

clinical practice, students learn procedural skills such as bathing, dressing, positioning, and vital signs along

with key communication techniques to provide compassionate care for people within the health care system.

American Red Cross classrooms/labs are equipped with hospital beds and all necessary medical equipment to

practice skills. After graduation, students are eligible to sit for their state/national exam for certification.

For the American Red Cross __________________________ Training Program, I have been informed that for

the July 2010/June 2011 period, the withdrawal rate is ______%, the completion rate is _____%, and the

in-field placement rate is _____%. Detailed statistical data for this program may be viewed by going to

http://state.tn.us/thec

and clicking on the “Authorized Institutions Data” button.

The American Red Cross is committed to a policy of providing equal educational opportunities to all candidates

regardless of economic or social status and does not discriminate on the basis of race, color, ethnic origin,

national origin, creed, religion, political belief, sex, sexual orientation, marital status, or age.

Please complete the information below

Last Name: First Name: MI:

SSN: - - Phone:

Home Address: Apartment #:

City: State: Zip:

County:

Phone Number: □Home □Cell □Other

Email Address:

*Place of Employment:

*Address & Contact Information of Employer:

*AMERICAN RED CROSS MUST REPORT EMPLOYER INFORMATION TO THE TENNESSEE HIGHER EDUCATION COMMISSION

15

Tuition: $1250.00

Tuition is due prior to the first day of class. We cannot accept cash or personal check as payment for this

course, but do accept credit/debit cards, money orders, and cashier‟s checks. Money orders and cashier‟s

checks should be made payable to: American Red Cross.

Tuition Includes:

 All classroom and clinical instruction  Textbook, workbook and class materials  Blood Pressure Cuff

 Stethoscope

 Water resistant watch with a second hand

 American Red Cross CPR/Automated External Defibrillator (AED) Certification  American Red Cross First Aid Certification

 American Red Cross Nursing Assistant Pin upon Graduation  The initial state testing fee ($88)

 Patient Care Kit/Supplies

Additional Costs (not included in tuition price)*

Scrubs

$35.00 TB Skin Test

$10.00

Clinical Shoes

$50.00

Physical Exams

Varies

*Please Note: These costs are only an estimate. Actual costs may vary

REFUND POLICY:

A full refund of all fees will be given if the classes are canceled or the student withdraws prior to the first day of

class less an administrative fee of one hundred dollars ($100.00)

A partial refund will be given as follows:

75% refund if a student withdraws within the first 10% of scheduled class hours less an administrative fee of

one hundred dollars ($100.00).

50% refund if the student withdraws within the first 20% of scheduled classes hours less an administrative fee

of ($100.00).

No refunds are permitted after the first 20% of scheduled class hours.

By signing below, you are verifying that you have received an exact signed copy of this enrollment agreement.

___________________________________________________________________________________

American Red Cross

Student Information Sheet

Date: ______________ CIRCLE ONE:

NAT EKG PHLEBOTOMY PATIENT CARE TECHNICIAN Mr. _____ Mrs. ___ Ms. ___

Last Name ____________________________ First Name ______________M.I. _____ SSN ______________-__________-_______________ Phone ___________________ Home Address ________________________________________ Apartment # _________ City _________________________________ State ______________ Zip ______________ County __________________________________

Phone Numbers:

Home: _________________________________________ Cell _______________________________________ Emergency Contact Name and Contact Information:

________________________________________________ Email Address ____________________________________

Note: The phone numbers and email address will be used to contact students while in the course (to send reminders, etc.) and after graduation (to forward job opportunities and track employment or continued education.)

In case of emergency, please contact: _______________________________ Phone _______________________________

Race: _____

A = African American C = Caucasian H = Hispanic O = Other

Sex: _____

Funded: Yes ____ No_____

If funded, what is the name of the agency? ________________________