Medical Assistant Application

Levy Medical Assistant Application

First Name

Last Name

Phone no.

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Date of Birth

Emergency Contact Name

Emergency Contact Phone Number

Highest Level of Education

Current Employer

Job Title

Are you currently employed?

Yes

Have you ever worked in healthcare?

Yes

If yes, please describe your healthcare experience.

Admission Requirements Acknowledgment

I have a valid government-issued photo ID.

I have a High School Diploma or GED.

I understand I must provide these documents before enrollment is complete.

I understand that official documentation must be provided before the first day of class.

understand that submitting this application does not guarantee acceptance into Levy Phlebotomy Academy.

I certify that all information provided in this application is true and accurate.

I agree to comply with all Levy Phlebotomy Academy policies and procedures.

Payment Agreement

I understand that a $100 enrollment deposit is required to reserve my seat in class.

I understand that the $100 deposit is non-refundable for any reason, including cancellation, failure to attend, or withdrawal from the program.

I understand that my seat is not guaranteed until my deposit has been received.

I understand that the remaining tuition balance is due before the first day of class unless I have an approved payment plan with Levy Phlebotomy Academy.

I understand that failure to pay the remaining balance by the due date may result in the loss of my reserved seat.

I understand that tuition payments already made may be subject to the school's refund policy as outlined in the Enrollment Agreement and Student Handbook.

I agree to all payment terms and understand my financial responsibility.

How will you pay your full/remaining tuition balance?

If you selected "Other," please explain.

Emergency Authorization

I authorize Levy Phlebotomy Academy to obtain emergency medical treatment if I become ill or injured during laboratory or clinical training and cannot be reached. I understand I am responsible for any medical expenses incurred.