Phlebotomy Technician CPT1 Certification Program

Phlebotomy Technician CPT1 Certification Program Enrollment Agreement

Statement of Understanding

The enrollment agreement is legally binding when signed by the student and accepted by Diablo Medical Training (aka DMT). This enrollment agreement walks the prospective student through the final enrollment process that includes a checklist of materials, program costs, and the documentation that each student must receive and understand before committing to this School’s program. As a prospective student you must sign this agreement as a final step in your eligibility to enroll in the Phlebotomy Technician CPT1 Certification Program.

IMPORTANT NOTICE AND INSTRUCTIONS: (1) Do not sign this agreement before you read it completely or if it contains any blank spaces not completed. (2) This agreement will be discussed in detail during the mandatory orientation period scheduled prior to the beginning of the first class. (3) If there is any part of the agreement you do not understand, the class instructor and-or the School’s Director is available to you to answer all questions to your satisfaction before you sign the agreement. (4) No money other than the application fee is required prior to the signing of this agreement. (5) Course materials, lectures, and certification test materials require English language proficiency. (6) Do not sign this agreement unless you fully understand its contents. (7) Student signature on this agreement (page 6) binds the student to the terms of this agreement including program costs.

Any questions a student may have regarding this enrollment agreement that have not been satisfactorily answered by the institution may be directed to the Bureau for Private Postsecondary Education at Address: 2535 Capitol Oak Drive, Suite 400, Sacramento, CA. 95833 PO box 980818, West Sacramento, CA. 95798-0818 Web site address: www.bppe.ca.gov Telephone and Fax Numbers: (888) 370-7589 or fax (916) 263-1897 (916) 431-6959 or fax (916) 263-1897 A student or any member of the public may file a complaint about this institution with the Bureau for Private Postsecondary Education by calling (888) 370-7589 toll-free or by completing a complaint form, which can be obtained on the bureau’s internet web site www.bppe.ca.gov.

DMT Version: 20160501 Page 1 of 16 Phlebotomy CPT1 Student Initials ( ) Phlebotomy Technician CPT1 Certification Program Campus: Diablo Medical Training (DMT) - Brentwood Address: 929 Second St., Suite 18, Brentwood, CA 94513 Phone number: (925) 586-2532 / Fax: 925.513.8230

Enrollment Agreement Course subject to Article 7 of the CEC

Last Name______First Name______Student SS#______CA Driver Lic.# Email address Current address: City, State, Zip Code HomePhone______WorkPhone______MessagePhone______Have you ever been convicted of a crime? Yes or No Emergency Contact Name: Phone: A. EDUCATIONAL SERVICE: Phlebotomy Technician CPT 1 Certification Program Total Tuition Cost: $2400.00 Total Clock Hours: 130 Total Quarter Credit Hours: 2.0 See Sections C – E below. B. SPECIFIC TIME OF CLASSES: (Circle) M T W TH FR Sat Sun Start Time: End Time: Didactic/Practical Start Date: ______Didactic/Practical End Date: ______Externship Start Date1: ______Externship End Date2: ______1 Externship hours (80) are scheduled after the student receives a passing grade on the course Final Examination. Start date varies from student to student. 2Externship is normally completed within 60 calendar days of the CPT 1 final examination, unless a written request for delay is submitted by the student at least one week prior to the scheduled externship start date. Externship slots are reserved in advance of student class graduation. The externship end date provided will be a Not Greater Than date. Certificate of Completion is issued when student externship is completed. C. TOTAL INSTITUTIONAL FEES: Registration Fee $75.00 (non-refundable); Tuition $2400.00 (refundable); STRF fee $0.00 (non-refundable); Liability Insurance $50.00; Supplies and Materials $125.00: Total Charges for Period of Attendance = $2650.00 D. REQUIRED OUT OF POCKET FEES (not paid directly to Diablo Medical Training): Uniforms $30.00 (non- refundable); BLS $55.00 (non-refundable); Drug Screen $35.00 (non-refundable); Books $88.00 (Eligible for Buy Back); California State Application Fee $100.00 (non-refundable): Total Estimated Out of Pocket Expenses = $308.00

DMT Version: 20160501 Page 2 of 16Phlebotomy CPT1 Student Initials ( ) Phlebotomy Technician CPT1 Certification Program E. PROFESSIONAL CONTINUATION FEES: National Certification Exam, $90.00, (non-refundable, non-DMT); California Department of Public Health Laboratory Field Services (CDPH-LPS) Application Fee, $100.00, (non- refundable, non-DMT) Total Professional Continuation Expenses = $190.00 F. ESTIMATED SCHEDULE OF TOTAL CHARGES FOR THE ENTIRE EDUCATION PROGRAM: $2958.003 3Includes additional out-of-pocket estimates and does not include option expenses listed in Sec. E

YOU ARE RESPONSIBLE FOR THIS AMOUNT. IF YOU GET A STUDENT LOAN, YOU ARE RESPONSIBLE FOR REPAYING THE LOAN AMOUNT PLUS ANY INTEREST, LESS THE AMOUNT OF ANY REFUND THAT IS DUE. IF YOU ARE SELECTING A PAYMENT PLAN TO PAY FOR TUITION, PLEASE SEE THE SEPARATE INSTALLMENT NOTE IN THIS ENROLLMENT AGREEMENT.

Student Cancellation/Withdrawal Refund Tuition and fee refunds are available if the student withdraws from the program, but prorated upon program completion. No refund is available after the student has completed 60% of the program. Students considering withdrawal from the program are requested to submit a Notice of Cancellation/Withdrawal form as soon as possible and prior to beginning the Externship portion of the program, if possible. The last day to qualify for a pro-rated refund is prior to the second day of scheduled Externship. Refer to refund information in your Student Catalog and beginning on Page 8 of this agreement.

Cancellation/Withdrawal Refunds on Federal or State Student Financial Aid If the student has received federal or state student financial aid funds, and if a refund is due to the student, the student is entitled to a refund of the money not paid from federal financial aid funds, subject to the refund policy described in this agreement and the school catalog.

Notice for Students Receiving Federal or State Student Financial Aid If the student is eligible for a loan guarantee by the federal or state government and the student defaults on the loan, both of the following may occur: (1) The federal or state government or a loan guarantee agency may take action against the student, including applying and income tax refund to which the person is entitled to reduce the balance owed on the loan. (2) The student may not be eligible for any other federal student financial aid at another institution or other government financial assistance at another institution until the loan is repaid. If you cancel, withdraw or are terminated from training, your financial obligation and refund (if any) will be under the conditions described in the "Cancellation" and "Withdrawal" sections that are included in this agreement.

DMT Version: 20160501 Page 3 of 16Phlebotomy CPT1 Student Initials ( ) Phlebotomy Technician CPT1 Certification Program STRF (Student Tuition Recovery Fund) STRF is a state requirement that a student who pays his or her tuition is required to pay a state imposed assessment for the student tuition recovery fund. All students that are residents of California that pay their tuition either by cash, guaranteed student loans, or personal loans must participate in the Student Tuition Recovery Fund (STRF). This institution is required to collect the assessment from each student in the Phlebotomy Technician 1 (CPT1) program at the time it collects the first payment from or on behalf of the student at or after enrollment. The assessment shall be collected for the entire period of enrollment, regardless of whether the student pays the institutional charges in increments. The rate for your program, beginning January 1, 2015 is zero ($0). The Non-Refundable STRF charge for your program will be based on the charge of $0.00 for $1,000.00 in tuition charges rounded to the nearest $1,000.00. The STRF rate is subject to change based upon the balance in the STRF account. Statute requires the Bureau begin collecting if the balance falls below $20 million ($20,000,000.00) and caps the account at $25 million ($25,000,000.00). The STRF was established by the Legislature to protect any student who attends a private postsecondary institution from losing money if you prepaid tuition and suffered a financial loss as a result of the school closing. You do not qualify by failing to live up to the school's enrollment agreement or refusing to pay a court judgment.

The following is a description of the students' Rights and Responsibilities with respect to the Student Tuition Recovery Fund: "You must pay the state-imposed assessment for the Student Tuition Recovery Fund (STRF) if all of the following applies to you: • You are a student in an educational program, who is a California resident, or are enrolled in a residency program, and prepay all or part of your tuition either by cash, guaranteed student loans, or personal loans, and • Your total charges are not paid by any third-party payer such as an employer, government program or other payer unless you have a separate agreement to repay the third party.

You are not eligible for protection from the STRF and you are not required to pay the STRF assessment, if either of the following applies: • You are not a California resident, or are not enrolled in a residency program, or • Your total charges are paid by a third party, such as an employer, government program or other payer, and you have no separate agreement to repay the third party."

The State of California created the Student Tuition Recovery Fund (STRF) to relieve or mitigate economic losses suffered by students in educational programs who are California residents, or are enrolled in a

DMT Version: 20160501 Page 4 of 16Phlebotomy CPT1 Student Initials ( ) Phlebotomy Technician CPT1 Certification Program residency program attending certain schools regulated by the Bureau for Private Postsecondary and Vocational Education. Students enrolled at the time of school closure (or within 60 days of the school's closure) may be eligible for reimbursement through the Student Tuition Recovery Fund (STRF). The STRF exists to relieve or mitigate economic losses suffered by a student in an educational program at a qualifying institution if the student was a California resident (or was enrolled in a residency program.) The student of a closed school must have:  Prepaid the tuition,  Paid the STRF assessment, and  Suffered loss An economic loss May be a result of any of the following: 1. The closure of the institution; 2. The institution's failure to pay refunds or charges on behalf of a student to a third party for license fees or any other purposes, or to provide equipment or materials for which a charge was collected within 180 days before the closure of the institution; 3. The institution's failure to pay or reimburse loan proceeds under a federally guaranteed student loan program as required by law or to pay or reimburse proceeds received by the institution prior to closure in excess of tuition and other costs; 4. A significant decline in the quality or value of the educational program within the 30-day period before the closure of the institution or, if the decline began before that period, the period of decline determined by the Bureau, to a degree that results in the institution's failure to meet minimum operating or academic standards; and 5. The student's inability to collect a judgment entered against a qualifying institution for a violation of the Act, subject to all of the following: a. The student has reasonably tried, and failed, to collect on the judgment. The Bureau will determine the reasonableness of the effort on a case-by-case basis; b. The Bureau receives the student's application within 4 years from the school's closure; c. The student has not received reimbursement or forgiveness from any other source. c.i. A student whose total charges were paid by a third-party payer is not eligible to make a claim.

However, no claim can be paid to any student without a social security number or a taxpayer identification number.

DMT Version: 20160501 Page 5 of 16Phlebotomy CPT1 Student Initials ( ) Phlebotomy Technician CPT1 Certification Program To qualify for STRF reimbursement you must file a STRF application within two years of receiving notice from BPPE that the school is closed. IF you do not receive notice from BPPE, you have four years from the date of closure to file a STRF application. If a judgment is obtained you must file a STRF application within two years of the final judgment. The STRF application for reimbursement may be found at the following link, http://www.bppe.ca.gov/forms_pubs/strf.pdf. Supporting documentation is required with the STRF application. It is important that you keep copies of the enrollment agreement, receipts or any other information that documents the monies paid to the school.

BPPE may conduct an investigation whether to grant or deny a claim, and they may ask for additional information. Upon payment of the claim, all of the student's rights against the institution for that amount of payment shall be deemed assigned to the Bureau. If the Bureau denies the claim, or reduces the amount of the claim, the Bureau may informally consider a written appeal and modify its decision. If a written appeal is not received by the Bureau within 30 calendar days from the date of the decision, the Bureau's decision shall be final.

Any questions regarding the STRF may be directed of www.bppe.ca.gov. 1-888-370-7589, BPPE, 2535 Capitol Oaks Drive, Suite 400, Sacramento California, 95833.

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Student Acknowledgements and Agreement Signature THE TERMS AND CONDITIONS OF THIS AGREEMENT ARE NOT SUBJECT TO AMENDMENT OR MODIFICATION BY ORAL AGREEMENT. I, THE UNDERSIGNED PURCHASER OF THE PROGRAM OF TRAINING, HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS CONTAINED HEREIN AND WITH MY SIGNATURE I CERTIFY HAVING RECEIVED AN EXACT COPY OF THIS AGREEMENT AND A COPY OF THE SCHOOL CATALOG, AND FURTHER ACKNOWLEDGE THAT NO VERBAL STATEMENTS HAVE BEEN MADE CONTRARY TO WHAT IS CONTAINED IN THIS APPLICATION. THE ENROLLMENT AGREEMENT IS A LEGALLY BINDING INSTRUMENT WHEN SIGNED BY THE STUDENT AND ACCEPTED BY THE SCHOOL. Student Initials ( ) I agree to attend all classes as scheduled, to perform all duties required by the School and abide by the rules and regulations of the School in accordance with the policies set forth in the current School catalog. I may be terminated from the School under the following conditions: failure to maintain passing grades; misconduct and I or failure to abide by the rules and regulations of the School; absences in excess of the maximum set forth by the School; failure to meet financial obligations to the School. Upon successfully completing all requirements of the program, I will receive a Course Completion Certificate. In order to graduate you must successfully pass the class. The school does not school offer formal Placement Assistance. The school cannot, in anyway, guarantee employment after the student has successfully completed the program of study. I have received a tour of the school facilities and inspection of equipment where training and services are provided. Student Initials ( ) Prior to signing this enrollment agreement, you must be given a Catalog or Brochure and a School Performance Fact Sheet, which you are encouraged to review prior to signing this agreement. These documents contain important policies and performance data for this institution. This institution is required to have you sign and date the information included in the School Performance Fact Sheet relating to completion rates, placement rates, license examination passage rates and salaries or wages, and the most recent three-year cohort default rate, if applicable, prior to signing this agreement. Student Initials ( ) I certify that I have received the catalog, School Performance Fact Sheet, and information regarding completion rates, placement rates, license examination passage rates, and salary or wage information, and the most recent three-year cohort default rate, if applicable, included in the School Performance Fact Sheet, and have signed, initialed, and dated the information provided in the School Performance Fact Sheet. Student Initials ( ) I further acknowledge that I understand and agreed to my rights and responsibilities, and that the institution's cancellation and refund policies have been clearly explained to me. Student Initials ( )

DMT Version: 20160501 Page 7 of 16Phlebotomy CPT1 Student Initials ( ) Phlebotomy Technician CPT1 Certification Program Student certifies that he/she has received each of the following documents initialed below and was allowed sufficient time to read and understand them: (Please initial for each document received.) ( ) Notice of Cancellation Form ( ) Copy of this Agreement ( ) Current School Course Catalog or Brochure ( ) Tuition and Fee Information ( ) School Performance Fact Sheet ( ) Notice of Student Rights ( ) Student Installment - Disclosure Form ( ) Pass/Fail Comp. Evaluation

TOTAL CHARGES FOR CURRENT PERIOD OF ATTENDANCE: $2,650 ESTIMATED CHARGES FOR THE ENTIRE EDUCATIONAL PROGRAM: $2,958.00. TOTAL CHARGES THE STUDENT IS OBLICATED TO PAY UPON ENROLLMENT: $2,650. See Pages 1 - 2 for details.

I understand that this Enrollment Agreement is a legally binding contract when signed by the student and accepted by the institution. My signature below certifies that I have read, understood, and agreed to my rights and responsibilities, and that the institution's cancellation and refund polices have been clearly explained to me.

Signed: ______Print Name: ______Signature of Applicant

Date signed ______

Accepted by: ______School Representative Title Acceptance Date

Any questions a student may have regarding this enrollment agreement that have not been satisfactorily answered by the institution may be directed to the Bureau for Private Postsecondary Education at Address: 2535 Capitol Oak Drive, Suite 400, Sacramento, CA. 95833 PO box 980818, West Sacramento, CA. 95798-0818 Web site address: www.bppe.ca.gov; Telephone and Fax #’s: (888) 370-7589 or fax (916) 263-1897, (916) 431-6959 or fax (916) 263-1897

BE SURE TO READ ALL PAGES OF THIS AGREEMENT. IT IS PART OF YOUR CONTRACT WITH THE SCHOOL.

DMT Version: 20160501 Page 8 of 16Phlebotomy CPT1 Student Initials ( ) Phlebotomy Technician CPT1 Certification Program Student's Right to Cancel 1. You have the right to cancel this agreement, including any equipment or other goods and services included in the agreement, and receive a full refund (less a deposit or application fee not to exceed $100) through attendance of the first class session, or the seventh calendar day after enrollment, whichever is later. 2. Cancellations due to rejection of application, program cancellation, no show/non starts, cancellation by student during the cancellation period, will receive a full refund (less a deposit or application fee not to exceed $125) within 30 days of cancellation date. 3. Your cancellation takes effect when you give written Notice of Cancellation to this school at the address shown on page 2 of this agreement. Any written expression that you wish not to be bound by this agreement will serve as a Notice of Cancellation of this agreement. Read the Notice of Cancellation form provided to you in this agreement. If you lose this Notice of Cancellation form, you may ask the school for another copy. 4. You are due a complete refund within 30 days after the school receives a valid Notice of Cancellation. 5. After the end of the cancellation period, you also have the right to stop school at any time; and you have the right to receive a pro-rated refund for the part of the course not taken. 6. Cancellation shall occur when the student provides a written notice of cancellation to the address of Diablo Medical Training: 925 Second Street, Suite 18, Brentwood, California, Attn: School Director. This can be done by mail, hand delivery, or fax (925) 513-8230. Notice of cancellation may also be sent via email to [email protected]. 7. The written notice of cancellation, if sent by mail, is effective when deposited in the mail properly addressed with proper postage; if sent by email, effective according to the email’s date and time stamp. 8. If the student has received federal or state student financial aid funds, and if a refund is due to the student, the student is entitled to a refund of the money not paid from federal financial aid funds, subject to the refund policy described in this agreement and the school catalog.

WITHDRAWAL: Withdrawing from a Course Students have the right to withdraw from a program of instruction until the 60% point of the course and receive at least a partial refund. Students are obligated to pay only for education services rendered and any unreturned equipment until the 60 percent point of the course, as measured in hours, no which will he possible. If the student has received federal student financial aid funds, the student is entitled to a refund from federal student program funds. Diablo Medical Training’s CPT1 certification course does not currently participate in federal student financial aid programs.

Last Day to Withdrawal for Refund The last day to withdrawal from the program and to qualify for a pro-rated refund is prior to the second day of the student’s scheduled Externship. This date will vary from student to student, class to class, but holds

DMT Version: 20160501 Page 9 of 16Phlebotomy CPT1 Student Initials ( ) Phlebotomy Technician CPT1 Certification Program true for the total clock hours assigned to the CPT1 program. The 60% point for the Phlebotomy Technician CPT1 Certification Program carries into the externship (practical) portion of student training. Students enrolled in the DMT CPT1 program will be scheduled for 80 hours of externship at one of this School’s approved clinical laboratories. Students are scheduled into externship on a space-available basis. DMT’s class size constraints is part of its service commitment to the student to complete the externship portion of the program, usually no later than 60 days after passing the certification test. However, the final schedule determination is not under DMT’s control. Student’s must pass the DMT certification test and receive their certificate of completion; AND the pass national MMCI in order to be scheduled for externship with an approved hospital.

Calculating Refunds The refund shall be calculated by (a) deducting a registration fee not exceeding $100 from the total tuition charge; (b) dividing this figure by the number of hours in the program; (c) the quotient is the hourly charge for the program; (d) the amount owed by the student for purposes of calculating a refund is derived by multiplying the total hours attended by the hourly charge for instruction; (e) the refund would be any amount in excess of the figure derived in step (f) that was paid by the student; and (g) the refund amount shall be adjusted for unreturned equipment. If a separate charge for equipment is specified in the agreement, and the student actually obtains the equipment, and the student returns that equipment in good condition allowing for reasonable wear and tear, within 30 days following the date of the student's withdrawal, the institution shall refund the charge for the equipment paid by the student. If the student fails to return that equipment in good condition, allowing for reasonable wear and tear, within 30 days following the date of the student’s withdrawal, DMT may offset against the refund calculated the documented cost to the institution of that equipment. The student is liable for the amount, if any, by which the documented cost for equipment exceeds the prorated refund amount. Equipment cannot be returned in good condition if the equipment cannot be reused because of health and sanitary reasons and this fact is clearly and conspicuously disclosed in the agreement. If any portion of the tuition was paid from the proceeds of a loan or third party, the refund shall be sent to the lender, third party or, if appropriate, to the state or federal agency that guaranteed or reinsured the loan. Any amount of the refund in excess of the unpaid balance of the loan shall be first used to repay any student financial aid programs from which the student received benefits, in proportion to the amount of the benefits received, and any remaining amount shall be paid to the student.

How Does Diablo Medical Training Calculate Refunds? Total program charge - Registration fee = Total program cost Total program cost DIVIDED program hours = Program fee per hour. Per hour program fee x hours attended = Total program charge Total program cost - Total program charge = Refund (The hourly program fee shall be multiplied by hours attended by student minus program charge equals refund.) DMT Version: 20160501 Page 10 of 16 Phlebotomy CPT1 Student Initials ( ) Phlebotomy Technician CPT1 Certification Program

Hypothetical Refund Example For example, if a student enrolls in a 100 hour program and withdraws after receiving 35 hours of instruction, and if the student paid a $75.00 registration fee and $2,000 tuition, the school would deduct the $75.00 registration fee from the amount received, divide the remaining $2,000 by the number of hours in the program (2000/ 100 = 20) and multiply that hourly amount times the number of hours received by the student (35 x 20 =$700.) The amount paid; in excess of that amount would be the amount of the refund. ($2,000 - $700 = $1,300) Refund Amount. In addition, the refund would include any amount paid for equipment, which is subsequently returned in good condition. If you attend class and drop before payment is made, you will be responsible for tuition accrued up to the date formal withdrawal notice is given.

If the school cancels or discontinues a course or educational program, the school will make a full refund of all charges. Refunds will be paid within 30 clays of cancellation or withdrawal.

IF THE AMOUNT THAT THE STUDENT PAID IS MORE THAN THE AMOUNT THAT THE STUDENT OWES FOR THE TIME ATTENDED, THEN A REFUND WILL BE MADE WITHIN 30 DAYS OF THE DATE OF DETERMINATION OF WITHDRAWAL. IF THE AMOUNT THAT THE STUDENT OWES IS MORE THAN THE AMOUNT THAT THE STUDENT HAS ALREADY PAID, THEN THE STUDENT WILL HAVE TO ARRANGE TO PAY IT.

Payment of Refunds Refunds are made within 30 days following the date upon which the student's withdrawal has been determined. Pre-contract Disclosure: If the student obtains a loan to pay for the course of instruction, the student will have the responsibility to repay the full amount of the loan plus interest, less the amount of any refund.

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NOTICE CONCERNING TRANSFERABILITY OF CREDITS AND CREDENTIALS EARNED AT OUR INSTITUTION The transferability of credits you earn at Diablo Medical Training is at the complete discretion of and institution to which you may seek to transfer. Acceptance of the Phlebotomy CPT 1 Certificate of Completion you earn in Phlebotomy Technician Training CPT 1 Program is also at the complete discretion of the institution to which you may seek to transfer. If the Phlebotomy CPT 1 Certificate of Completion that you earn at this institution are not accepted at the institution to which you seek to transfer, you may be required to repeat some or all of your coursework at that institution. For this reason you should make certain that your attendance at this institution will meet your education goals. This may include contacting an institution to which you may seek transfer after attending Diablo Medical Training to determine if you Phlebotomy CPT 1 Certificate of Completion will transfer.

STUDENT CREDIT/CREDENTIALS EVALUATION AND TRANSFER Diablo Medical Training allows for the transfer of credits earned at another institution if that institution is Nationally or Regionally accredited by an agency recognized by either the U. S. Department of Education or the Council for Higher Education, and if the previous credits earned are comparable to those offered in the institution's program in which the student seeks to enroll. All considered credits must have been earned within the last three years, and be of "C" average or above. Diablo Medical Training will allow no more than 50% of any program to be credited by transferring credits from another institution. Course credits for advanced placement through outside examination may be considered, but are generally not accepted. There is no fee for the evaluation or the granting of transfer of credit.

A written request for credit transfer must be made to the Campus Director at least two weeks prior to the start of class, in order to allow Diablo Medical Training adequate time for evaluation. Requests made with less than 2 weeks prior notice will not be evaluated. The request must include an official transcript from the student's prior institution, and course descriptions in the form of syllabi or institutional catalogs which include clock and/or credit hours. A decision will be made within one week of receipt of the requisite documents, and the student will be advised by mail or email. Any appeal to the institution's decision must be made in writing and submitted to the Campus Director. The subsequent decision will be final.

Any reduction in tuition resulting from the transfer of credits will be based on the per hour cost of training for the program times the number of clock hours of the institution's comparable program for which the student is being given credit. The student is allowed and encouraged to sit, free of charge, for purposes of review, any portions of the program for which she/he has been given credit, as long as classroom space is

DMT Version: 20160501 Page 12 of 16 Phlebotomy CPT1 Student Initials ( ) Phlebotomy Technician CPT1 Certification Program available. If an enrollment agreement had been signed by the student prior to a request for credit transfer, and credit is accepted, a new enrollment agreement must be signed to include any changes to the amount of financial obligation of the student due to the transfer of credit. Diablo Medical Training makes no guarantee of transferability of credits to another institution, but will assist the student wishing to "transfer out" by providing guidance, and providing official transcripts, syllabi, course outlines, or institutional catalogs as requested, at no charge to the student. At this time the Institution does not have any written articulation agreements with other proprietary, post-secondary or other institutions of higher learning.

Enrollment Agreement-Installment and Disclosure Statement

Date ______

As payment for tuition at Diablo Medical Training, I promise to pay the school, the sum of $______for the following ______Installments, see you Disclosure Statement – Payment Schedule below. Sign here ______Date ______Print Name ______Address______City______State ______Zip ______Home Tel: ( ) ______Work Tel: ( ) ______Social Security #______-______-______

The terms and conditions contained in the Enrollment Agreement and the “Disclosure Statement,” which is incorporated herein by reference as though set forth in full. Should default be made in any payment when due, the whole sum shall immediately become due and payable.

Be signing below the buyer acknowledge receipt of a completed and true copy of his installment contract and jointly and severally agrees to all of the terms and conditions.

Method of Payment accepted by Diablo Medical Training is cash, credit card, personal/business check, money order, and ATM/Debit card.

DISCLOSURE STATEMENT-YOUR PAYMENT SCHEDULE WILL BE:

Number of payments ______Amount of each payment ______weekly/monthly/other______Beginning on ______and ending on ______.

LATE CHARGES: if any payment is more than 10 days late you will be charged $50.00 late fee.

PREPAYMENT: Prepayment is allowed at any time.

DMT Version: 20160501 Page 14 of 16 Phlebotomy CPT1 Student Initials ( ) Phlebotomy Technician CPT1 Certification Program NOTICE TO BUYER: (1) Do not sign this agreement before you read it or if it contains any blank spaces to be filled. (2) You are entitled to a completely filled-in copy of this agreement. (3) You can prepay the full amount due under this agreement at any time.

Any questions a student may have regarding this enrollment agreement that have not been satisfactorily answered by the institution may be directed to the Bureau for Private Postsecondary Education at Address: 2535 Capitol Oak Drive, Suite 400, Sacramento, CA. 95833 PO box 980818, West Sacramento, CA. 95798-0818; Web site address: www.bppe.ca.gov; Telephone and Fax #’s: (888) 370-7589 or fax (916) 263-1897 (916) 431-6959 or fax (916) 263-1897

A student or any member of the public may file a complaint about this institution with the Bureau for Private Postsecondary Education by calling (888) 370-7589 toll-free or by completing a complaint form, which can be obtained on the bureau’s internet web site www.bppe.ca.gov.

Notice of Cancellation/Withdrawal Form

Student Name: (Print) Course/Program Name: Phlebotomy Technician CPT1 Certification Program Enrollment Date (First Day of Class):

With my signature below, I hereby give notice to Diablo Medical Training of my desire to withdraw from the above named course on this date . I understand that if the date shown is immediate, the date of the Notice of Cancellation will default to the post mark date if the notice is sent via US mail, or the email or fax date stamp when the notice is received. If the written notice of cancellation is hand delivered, it must be delivered to the instructor or the School Director of Diablo Medical Training; the date of the hand delivery is the date of cancellation/withdrawal. I also understand that my right to a refund to any tuition and fees paid is subject to the terms shown in my enrollment agreement.

Student Signature Date

Check method of delivery ( ) US Mail ( ) Email ( ) Hand Delivered ( ) Fax

US Mail or Hand Delivery Address: Email Address: Diablo Medical Training Mary Lightell, School Director 929 Second Street, Suite 18 [email protected] Brentwood, CA 94513 Fax Number: (925) 513-8230

Do Not Write Below This Line, For Diablo Medical Training Use Only

Date Received Received By Title Notice received prior to the second day of externship? (Y) (N) Payment of tuition and fees current to date of withdrawal request? (Y) (N) Diablo Medical Training Library materials returned? (Y) (N) Voluntary Exit Survey Given/Received? (Y) (N)

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