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? _______________________________
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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
