Application & Payment – Levy Phlebotomy Academy

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)

Do you have any health conditions that could affect participation?

How did you hear about Levy Phlebotomy Academy?

Program Applying For:

Preferred Class Format:

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

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

Choose Your Enrollment Option

Full Tuition ($1,000)

Pay your tuition in full and secure your enrollment immediately. Includes access to online instruction, hands-on training, career preparation, and certification pathway support.

Reserve Your Seat ($250 Deposit)

Secure your seat today with a non-refundable $250 enrollment deposit. Remaining tuition balance can be paid through an approved payment arrangement before course completion.

Make Biweekly Payment ($250)

Already enrolled? Use this option to make your scheduled tuition payment securely through Stripe. Please include the student’s full name when submitting payment.

Next Class Starts June 22, 2026