�鶹��Ƶ RMH School of Phlebotomy Technician

Application for Admission

�鶹��Ƶ RMH Medical Center does not discriminate on the grounds of race, color, religion, national origin, sex, age, marital status, sexual orientation, family responsibilities or political affiliation.

Date

What class are you applying to (January, May, or August) and year?

Name

First name

Last name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Please list other names that you have used which may appear on requested documents such as transcripts

How did you hear about the school?

NOTE: If an applicant is accepted into the �鶹��Ƶ RMH School of Phlebotomy Technician, a physical examination, drug screen are required and background checks are also required.

Education

You must have a High School diploma with a minimum 2.6 grade point average OR a GED with a score between 175 - 200 upon starting the program and be at least 18 years of age upon starting the clinical rotation.

What is your present Grade Point Average?

What is your GED score?

Provide the names and addresses of the schools you have attended, the dates of attendance, and any diploma or degree(s) received.

References

Contact a minimum of three references and have them send letters of recommendation to the �鶹��Ƶ RMH School of Phlebotomy Technician. At least two of the references must be from high school teachers, college professors, or employers.

Work Experience

In the space below, list your work experience with the most recent employment first.

1. Date of employment

Name of Employer

First Name

Last Name

Employer's Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title

Reason for leaving

Interview

Acceptance into the �鶹��Ƶ RMH School of Phlebotomy Technician depends upon your references, analysis of academic courses and performance, and your personal interview. After all of your references and transcripts have been received and evaluated, an interview may be scheduled. The Program Director for the school will contact you regarding the date and time.

However, to assist in this process, please indicate the two best days and times to schedule the interview (for example, “Monday, any time after 1:00 pm”). Interviews will be scheduled Monday through Friday only.

Applicants without United States citizenship only. What is your current Visa status?

Applicant Questions

Why do you want to be a phlebotomist, and why have you selected �鶹��Ƶ RMH Medical Center?

Have you ever been convicted of a crime other than a minor traffic offense (including Military Service)?

YesNo

(The �鶹��Ƶ RMH School of Phlebotomy Technician conducts criminal record checks. Failure to divulge complete information will disqualify you from entrance into the school.) If yes, please state date, court and nature of offense.

Signature

If I am accepted by the �鶹��Ƶ RMH School of Phlebotomy Technician, I agree to abide by the code of ethics and the general rules and policies of the school and the hospital, and I am responsible for my conduct at all times. In signing below, I also affirm that to the best of my knowledge, the previous information is correct and accurate.

Signature

Type your first and last name above as your digital signature.

Send application, recommendations, and official transcripts, to:

�鶹��Ƶ RMH Medical Center Laboratory Schools
2010 Health Campus Drive
Harrisonburg, VA 22801