Hawaii Health Care Institute

(The “LEI” of Hawaii)

PHLEBOTOMY TECHNICIAN COURSE
email: admin@apexhi.net
__________________________________________________________________________________________
305 Wailuku Drive, Suite 6
Tel: (808) 933-1295
Hilo, Hawaii 96720
Fax: (808) 933-2722
APPLICATION FORM
Name: _______________________ Social Security Number: ________________
Address: _____________________ Phone: (Home) ________________
_____________________ (Cell) _______________ (Work) ______________

18 years age or older? Yes No

US Citizen? Yes No Green Card? Yes No

Have you ever been convicted of a crime or had traffic violation (s) by any court? Yes No
If Yes, please explain nature of the incident and current status on space provided below:

_________________________________________________________________________________

_________________________________________________________________________________

If applicable, will you be able to provide letters from your probation officer? ______________

If applicable, will you be able to provide at least three (3) letters of recommendation? ______

Emergency Contact Person: ___________________ Phone: ______________

Address: __________________________

__________________________

How did you hear about Hawaii Health Care Institute? _______________________________

♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦

Agency Sponsored? Yes No Name of Agency ____________________

Contact Person ________________ Phone Number
____________________

How did you hear about Hawaii Health Care Institute? _______________________________

Tuition Fee: $575.00 Non Refundable Registration

Fee: $150.00
 STUDENT AGREEMENT

I agree to release and hold harmless, Hawaii Health Care Institute, its staff and clients

who provides my training and clinical practice from any accidents or misconduct that arises

during the period of my training.

I certify that all statements made here on this application are true to my knowledge.

_____________________________
Student’s Name (Printed)

_____________________________
Signature

_____________________________
Date
 Hawaii Health Care Institute
(The “LEI” of Hawaii)
PHLEBOTOMY TECHNICIAN COURSE
email: admin@apexhi.net
__________________________________________________________________________________________
305 Wailuku Drive, Suite 6
Tel: (808) 933-1295
Hilo, Hawaii 96720
Fax: (808) 933-2722

PHYSICAL EXAMINATION FORM

Name: _______________________ Sex: F M Date of Birth: _____________

Address: ______________________ Phone: _____________ Cell _______________
______________________ email: ________________

Any serious illness? Yes No

If YES, please explain _______________________________________________________

Any Surgery or Injury? Yes No

If YES, please explain _______________________________________________________

Have you received treatment or counseling for alcohol, drug related or emotional
problems? Yes No If YES, please specify
____________________________

Do you have any type of handicap which limits function? _________________________

Are you able to lift fifty pounds? Yes No

Results of PPD

Ist Step Date Taken: __________________ Date Read: _______________

Results: _____________ Results: ______________

2nd Step Date Taken: __________________ Date Read: _______________

Results: _____________ Results: _______________

Chest X-Ray if Positive PPD

Date: _____________________ Results: _________________

Attending Physician: _________________________ Date: _______________

 PHYSICAL EXAMINATION VERIFICATION
(To be completed by Physician )

Significant Medical History pertinent to the student’s ability to participate in the Phlebotomy
Technician Course:
__________________________________________________________________________

Are there medications which may affect the student’s mental or physical performance?

__________________________________________________________________________

Current complaints affecting the student’s ability in the Phlebotomy Technician Course?

__________________________________________________________________________

I have examined _______________________________, and have found him/her not

to have any communicable disease or any health condition that is hazardous to him/her self,
patients, visitors or anybody.

He/she is physically and emotionally fit for the Phlebotomy Technician Course and/or
employment.

___________________________
Physician’s Name (Print)

___________________________
Physician’s Signature

___________________________
Date

I, ________________________, give permission to release this health information to Hawaii

Health Care Institute.

____________________________
Student
____________________________
Signature
___________________________
Date