Thank you for your interest in the PHLEBOTOMY program. Admission is by this application and only completedapplications will be accepted. There are sixteen (16) spaces available. Applicants must be at least 18 years of age. The registration fee is $223.00 which includes: $180 registration, $5 technology, $15 security, $2accident insurance, $16 malpractice insurance, and $5CPR card. The required textbook is approximately $70.

Phlebotomy training prepares students to draw blood specimens from patients for testing and analyzing. A phlebotomist maintains equipment used in obtaining blood specimens; use of appropriate communication skills when working with patients; selection of venipuncture sites; the care of blood specimen; entry of the testing process in the computer; as well as clerical duties associated with record keeping of blood tests. The course consists of theory and clinical experiences in performing blood collection. CPR training is included in this program; CPR book required, cost is (approximately $20).

The Division of Continuing Education of Wilson Community College recognizes and is fully supportive of clinical agencies that require a drug screen, background check, or fingerprinting on students. Costs of these tests are the responsibility of the student. The College has partnered with castlebranch.com for these tests. No other provider will be accepted. Students have ten (10) days after class begins to complete this task and sign up with castlebranch.com.The cost is $90. Students are to log in using the link: Phlebotomy program requires: Drug screen, Background check and Medical Document Manager: WD71.

APPLICATION REQUIREMENTS

Completed and signed application with the following required copies attached. It is the student’s responsibility to obtain these copies. Wilson Community College will not make copies.

Keep your original records and BRING COPIES ONLY.

High school diploma, high school equivalency,or transcript

North Carolina picture ID (example: driver’s license)

Proof of following immunizations:

  • Two TB skin tests (within twelve (12) months of class start date)
  • Two MMR(Mumps, Measles, Rubella)
  • ThreeHepatitis B (at least the first shot isrequired prior to start of class)
  • Varicella injection or Titer (blood test to prove immunity to chicken pox)
  • Flu shotrequired
  • Tdap (within the past 10 years)

REQUIRED prior to clinical rotations:

UNIFORMS: Purple V-neck shirt; white pants, white lab coat, and white, closed-toe shoes. Skirts and/or dresses must be approved by the Instructor prior to clinical rotation. Uniforms are available at Wilson Community College’s Bookstore. Students must be dressed professionally at all times when in clinical setting. Body piercings and tattoos must be covered when in clinical. Instructor will inform students of guidelines for dressing professionally.

PHLEBOTOMYAPPLICATION forSPRING 2018

SECTION# 30306

January 10th – May 7th(last day to register is Jan. 9th)

Mondaysand Wednesdays of each week

5:00 p.m. until 9:00 p.m.

Building: GRoom: 119

**Clinical hours will be scheduled during the daytime hours and students are required to complete 40 hours in the clinical setting**

The Program Coordinator will review and approve applications for those students who wish to pre- register. Applications will be available starting on October 5th. Students wishing to have applications approved are welcome to call 252-246-1325 for any questions regarding the approval process. Classes fill up quickly so pre-registration is encouraged. Once your application has been approved, you will be eligible to register and pay the $223 beginning November 6th. Registration will continue until the class is fullorthe day before the class is scheduled to start.Mail-in applicationsWILLNOTbe accepted.

NAME: Last: ______First: ______Middle Initial: ______

ADDRESS: ______City/State: ______Zip: ______

PHONE: Home: ______BIRTHDATE: ______Month ______Day ______Year

Cell: ______SEX:_____Male _____Female

RACE: ____White ____Black ____American Indian ____Hispanic ____Asian ____Other

EMPLOYMENT: ___Unemployed ___Part-Time ___Full-timeEMPLOYER: ______

YOUR CAREER PLANS: ______

DO YOU HAVE PREVIOUS EXPERIENCE IN THE HEALTHCARE FIELD? ___Yes ___No

IF YES, PLEASE LIST: ______

AGREEMENT

I have attached all required copies to my application; I have read, understand, and agree to all stated requirements of the Phlebotomy program; I understand the required clinical dress code, and agree to comply upon acceptance; I understand this is an application only and does not constitute acceptance into the program. I understand that I will be dismissed from the program if documented as verbally or physically abusive to college administration, clinical site staff, patients, or visitors.

SIGNATURE: ______DATE: ______

THIS MUST BE SIGNED AND WITNESSED AT TIME OF REGISTRATION: If any facility prohibits the student from participating in the clinical experience, the student will be dismissed due to an inability to progress and complete the program.

______

Student’s signatureSignature of WitnessDate