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Wagner Training Institute

PMB 275

700 E. Redlands Blvd., Ste. U

Redlands, Ca. 92373-6109

(800) 845-8353 fax (909) 795-4926

Phlebotomy Course of Instruction / Registration Form

1. Your total tuition fee is $200.00 A minimum deposit of $50.00 should accompany the completed registration form. Your balance is due on the first day of class (in the form of cash, cashiers check or money order). 2. Your tuition will include: Your Phlebotomy Handbook, all equipment to perform your practice punctures, coverage insurance, your certificate and a letter of recommendation.

3. Class hours: 10 hours each day. A total of 20 hours of Instruction. Students should arrive by 7:45 in order to complete the registration process.

4. Classes are instructed by Licensed Physicians, Medical personal, and experienced Phlebotomist.

5. Continuing Educations Units will be available for Licensed personal: Medical Assistance, Registered Nurses, Licensed Vocational Nurses, Emergency Medical Technicians, and Certified Nursing Assistance.

6. Student Charges: registration $50 + handbook $15 + equipment $55 + tuition $80= $200.00 total fee's due from students. There will be a $20 service charge for returned checks and for certificate replacement.

7. Tuition Refund Policy and Buyers Right to Cancel: Any written contract or agreement signed by a prospective student shall not become operative until the student attends the first class of instruction. The student has the right to cancel this registration agreement and may obtain a tuition refund as follows: A full refund, less the registration fee ($50) will be paid if the student cancels this agreement in writing prior to the Thursday (12:00 noon) prior to the course. Thereafter, the student may withdraw from the class and receive a pro rata refund less the ($50) registration fee, the ($15) handbook fee, the ($75) equipment fee, if the student has notified the school or the instructor in writing the students intent to cancel and has completed 60% of the class or less. For example, if the student has paid $200.00, and has completed 8 hours of the 20 hours of instruction and has notified Wagner Training Institute or students instructor in writing of his or her intent to withdraw, then the student would be entitled to a refund of $60.00 ($200.00, less the $50 registration fee, $15 handbook, $40 equipment fee and $35 tuition for 8 hours of class). No student is eligible for a refund after the conclusion of the 10th. hour of the class. In the event Wagner Training Institute cancels the class for any reason, the student is entitled to a full refund of all charges. All refunds are payable within 30 days. All notices of cancellations or withdrawal should be presented to the class instructor or sent to Wagner Training Institute, PMB 275, 700 East Redlands Blvd., Suite U, Redlands, CA 92373-6109. This form is legally binding when signed by student and accepted by W.T.I.

8. Disclosure: "We are registered with the State of California. Registration means we have met certain minimum standards imposed by the state for registered schools on the basis of our written application to the state. Registration does not mean we have met all of the more extensive standards required by the state for schools that are approved to operate or licensed or that the state has verified the information we submitted with our registration form."

9. Any questions or problems concerning this school that have not been satisfactorily answered or resolved by the school should be directed to the Bureau for Private Postsecondary and Vocational Education in the Department of Consumer Affaires, 1027 10th. Street, 4th. Floor, Sacramento, CA 95814, (916) 445-3427.

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REGISTRATION FORM

(Please print your name the way you want it to appear on your certificate)

NAME:_______________________________________________

Cashiers Check # _______________________________________

ADDRESS ____________________________________________

Money Order # ________________________________________

CITY Zip _____________________________________________

Check # ______________________________________________

PHONE: ______________________________________________

Deposit $ _____________________________________________

Class Location _________________________________________

Balance $ ____________________________________________

Class Dates: ___________________________________________

SIGNATURE DATE: Sex (M/F)___________________________________________________________________