Phlebotomy Application All Information On This Form Is

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PHLEBOTOMY APPLICATION
ALL INFORMATION ON THIS FORM IS HELD CONFIDENTIAL
The average time a student may wait to enter a class varies according to class availability
Students must register with their legal name on all documents, names must match exactly.
(PRINT)
Last Name: _____________________ First Name: ___________________________ Middle Name: _______________________
Maiden Name: ________________________ Social Security #: __________________ Birth Date: _________________________
Mailing Address: ___________________________________City: _________________State: ________Zip: _________________
Home #: ________________________Cell #: ___________________________Email: __________________________________
RESIDENCY INFORMATION
State of legal residency: ___________________________ Place of Birth: ____________________________________________
EDUCATION INFORMATION
Check one: High School Diploma
or GED
School & Location attended: ________________________________________________
ENROLLMENT INFORMATION
Have you attended RCCC before?
Yes
No
If yes, what year? ________________________________________________
Name under which you attended (if different): _________________________________________________________________
Program of study in which currently enrolled: __________________________________________________________________
Are you required by your employer to take this course?
Yes
No
****Student Background Check and Drug Test are required by the clinical facility for this program. This process must be
completed before you will be allowed to register. For detailed instructions regarding this requirement contact Claude Lingle at
704-216-3553.
PERSON TO CONTACT IN CASE OF EMERGENCY
Name____________________________________________Relationship____________________________________________
Home Telephone # ______-_______-__________ Cell # ______-_______-__________ Business # ______-______-___________
The Phlebotomy Application and copies of all required documents must be turned in at time of registration. Students who
are currently enrolled in any curriculum programs at RCCC still must follow the procedure above.
Phlebotomy Classes are taught four times a year with 10-14 students admitted to each class. Please check our website for
all class dates, times and locations. You can also download the application with the list of all requirements needed at time of
registration.
The Phlebotomy Class is a sixteen-week course. (Designated holidays may extend course time)
The RCCC Phlebotomy Class is taught only during the day at our Salisbury Campus location.
The class room hours of the class are usually set from 8:30 am to 12:30 pm.
The class is two days a week on Tuesday and Thursday.
The clinical days and hours of the Phlebotomy Class will vary.
I certify that the information given is complete and accurate. I agree to abide by all RCCC policies and regulations as
described in our website handbook.
Signature: ____________________________________________________________________________________________
Date: ________________________________________________________________________________________________

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