Contact Form – levyacademy.com

Contact Form Demo (#3)

First Name

Last Name

Date of Birth

Gender (Optional)

Social Security Number (last 4 digits only — optional but good for background checks or certification)

Phone Number

Email Address

Home Address (Street, City, State, ZIP)

Highest Level of Education Completed

Currently Employed? (Yes/No)

Employer Name (if applicable)

Previous Medical or Healthcare Experience? (Yes/No + Describe)

Program Applying For (e.g., Certified Phlebotomy Technician Training)

Desired Start Date / Session

How did you hear about Levy Phlebotomy Academy?

Do you have any health conditions that could affect participation?

Are your vaccinations (including Hepatitis B) up to date? (Yes/No)

Emergency Contact Name

Phone Number

Acknowledgments & Consent

I certify that all information provided is accurate.

I understand tuition payments are non-refundable after class starts.

I consent to be contacted by Levy Phlebotomy Academy via text/email.

I understand Levy Phlebotomy Academy is a mobile training institution; locations vary.

I acknowledge that I have read and agree to the Student Handbook & Refund Policy.

Student Signature (digital or handwritten)

Date / Time

Staff Signature (for office use)

Which class would you like to enroll in?

All payments are securely processed through Stripe.

Classes begin March 16, 2026.
All class sessions will be held online until further notice.