EKG Application – Levy Phlebotomy Academy

PCT Application

First Name

Last Name

Date of Birth

Phone Number

Email Address

Home Address (Street, City, State, ZIP)

Highest Level of Education Completed

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?

Have you ever worked in patient care?

Preferred Class Format:

Acknowledgments & Consent

I understand that successful completion of the PCT Program does not guarantee employment.

I understand that I must successfully complete all course requirements to receive a certificate of completion.

Student Signature (digital or handwritten)

Date / Time