Phlebotomy Technician Certificate Program Application

Phlebotomy Technician Certification Program Application for Admission

Phlebotomy Technician Certification Program Eligibility and Submission Checklist

ELIGIBLE STUDENTS SHALL:
  • Be a minimum age of 18 years old
  • Possess a high school diploma, GED or HiSet
  • Comply with MCC’s application procedures
  • Comply with MCC’s tuition requirements
  • Possess current health insurance
SUBMISSION CHECKLIST:
Please complete the following and submit as a whole package to MCC Workforce Development Center.
  • Application for Phlebotomy Technician Certificate Program Admission
  • Workforce Development Center Non-credit Registration Form
  • A copy of resume
  • Proof of Transcript: High School, GED, HiSet, or higher education
  • Immunization Record (ALL immunizations and HepB must be completed before lab/practicum) and a copy of your recent physical exam if available
  • Proof of Liability insurance and Health insurance
Applicants will complete and submit the following if required by sponsoring employer or if applying directly to program without an employer sponsorship:
  • Completed Criminal History Background Check form, found at:
    https://services.dos.nh.gov/chri/cpo/ ($25 fee assessed by the State of NH)
  • Drug Screening (estimated fee of $35-75). Location to be determined with MCC once your application is complete and submitted.
  • Copy of current CPR/First Aid Certificate (American Heart Association Professional Rescuer) required only if doing an externship with the program.
Non-Discrimination Policy

Manchester Community College does not discriminate in the administration of its admissions and educational programs, activities, or employment practices on the basis of race, color, religion, national origin, age, sex, disability, veteran status, sexual orientation, or marital status. This statement is a reflection of the mission of the Community College System of New Hampshire and Manchester Community College and refers to, but is not limited to, the provisions of the following laws

  1. Title VI and VII of the Civil Rights Act of 1964
  2. The Age Discrimination Act of 1967 (ADEA)
  3. Title IX of the Education Amendment of 1972
  4. Section 504 of the Rehabilitation Act of 1973
  5. The Americans with Disabilities Act of 1990 (ADA)
  6. Section 402 of the Vietnam Era Veteran’s Readjustment Assistance Act of 1974
  7. NH Law Against Discrimination (RSA 354-A)

Inquiries regarding discrimination may be directed to the Vice President of Student Affairs, Manchester Community College at (603) 206-8000, to Karen Graham, Director of Human Resources for the Community College System of New Hampshire, 26 College Drive, Concord, NH 03301, (603) 271-6300. Inquiries may also be directed to the US Department of Education, Office of Civil Rights, J.W. McCormack Post Office and Courthouse, Room 701, 01-0061, Boston, MA, 02109-4557, (617) 223-9662, FAX (617) 223-9669, TDD (617) 223-9695, or Email [email protected]; the NH Commission for Human Rights, 2 Chennell Drive, Concord, NH 03301, (603) 271-2767, FAX (603) 271-6339; and/or the Equal Employment Opportunity Commission, JFK Federal Building, 475 Government Center, Boston, MA, 02203, (617) 565-3200 or 1-800-669-4000, FAX (617) 565-3196, TTY (617) 565-3204 or 1-800-669-6820.

Phlebotomy Technician Certification Program Application for Admission

GENERAL INFORMATION

Name
MM slash DD slash YYYY
Gender
Address
Mailing Address (if different from above)
Untitled
Are you a U.S. Citizen?
If No, are you a permanent resident?
Ethnicity (Optional):

Emergency Contact Information

HIGH SCHOOL LAST ATTENDED

Address

COLLEGES PREVIOUSLY ATTENDED (list all colleges you have attended)

List
School Name
City
State
Dates Attended
 

NEW HAMPSHIRE RESIDENCE INFORMATION

I have always lived in New Hampshire

TO BE SIGNED BY ALL APPLICANTS

The information provided by the applicant on this admission application form shall be held confidential to the extent determined by Federal Law and College policy. Manchester Community College reserves the right to deny admission to any applicant who, in the judgment of the college officials, does not qualify for admission. The College also reserves the right to require withdrawal of any student who does not satisfy the ideals of citizenship, character, or scholarship. In accordance with the terms and conditions set forth in its publications, and if accepted to abide by the rules and regulations set forth in the publications and in the Student Handbook, I also agree that the College has permissions to use any College sponsored pictures in which any likeness appears. I certify that I have read and agree with the above, and that all information provided herein is true and complete.

Clear Signature
MM slash DD slash YYYY
For compliance purposes, the Community College System of New Hampshire and its Colleges collects names and social security numbers from all students attending the college. For example, the Internal Revenue Code requires the college to produce a 1098-T tax form. The college’s use of social security numbers will be limited to legitimate educational purposes. The college will ensure the security of the student’s social security number and will not disclose it to anyone outside the college, except as authorized by federal or state laws or applicable policies.

Non-Credit Registration Form

(Complete all items.)

GENERAL INFORMATION

MM slash DD slash YYYY
Name
Address
Mailing Address (if different from above)
Who is paying:
If Employer/Agency is paying, please provide their contact information:

FEDERAL GOVERNMENT STATISTICAL INFORMATION: (Optional)

Gender
Race
Ethnicity
Armed Forces Status

COURSE REGISTRATION

Course #

NCHC125M

Course Title/Description

Certified Phlebotomy Technician

Tuition

$1,500

Financial Obligation Statement - I understand by registering for courses at MCC, I am financially obligated for ALL costs related to the registered course(s) by the established tuition deadline, or I may be subject to withdrawal from course(s). Upon a drop or withdrawal, I understand I will be responsible for all charges as noted in the student catalog and handbook. I further understand that if I do not make payment in full, my account may be reported to the credit bureau and/or turned over to an outside collection agency. I also understand that I will be responsible for the cost of the outside collection agency, any legal fees and any bounced check fees under RSA 6:11, which will add significant costs to my account balance.

Refund Policy - Students registered for non-credit courses, workshops, or seminars must notify the Workforce Development Center in writing at least three business days prior to the first session and submit a Drop Form to receive a full refund minus any fees, if applicable. If students registered online or with a credit/debit card, there is a 7.0% transaction fee and $1.99 administration that will be deducted from your refund. You can avoid these fees by paying with cash or check in person at the college. Students who cancel within 3 business days prior to the first session of class will not receive a refund.

*The Workforce Innovation and Opportunity Act (WIOA), designed to help job seekers access employment, education, training, and support services to succeed in the labor market and to match employers with the skilled workers they need to compete in the global economy requires that we obtain information from students. The use of your social security number is requested in order to access wage and employment information through the state Unemployment Insurance wage information database to conform to WIOA regulations. You cannot be denied enrollment for failure to provide your social security number although we strongly encourage you to do so in order to enable the program to determine employment related outcomes. Your personal information will be kept confidential and secure and will not be shared with any outside agencies other than New Hampshire Employment Security.

Registrations will NOT be processed if you have an outstanding obligation to MCC. Upon registration, you are enrolled unless otherwise notified. Classes are subject to change. Students need to visit the MCC website and proceed to the Student Information System (SIS) for their classroom location(s), schedule, grades, financial aid information, student email account, etc.

Clear Signature
MM slash DD slash YYYY