<p> Caregiver Training School 1320 Kalani Street Suite 288, Honolulu, HI 96817 Phone: (808)848-9988 Email: [email protected] </p><p>Enrollment Agreement Course Title: PHLEBOTOMY TECHNICIAN TRAINING PROGRAM</p><p>Student Name: (Please Print) Cell No:</p><p>Address:</p><p>SSN: XXX-XX - ______Date of Birth: Age: Gender: M F</p><p>Class Date: Weekend Email:</p><p>Special Tuition ...... $1,199.00 Regular Price $2,041.00 (Over 40% OFF) </p><p>Tuition $1199.00 Textbook ...... 98.00 National Certification Exam ...... 155.00 Basic EKG Class ...... Free (Regular Price $195.00) I.V. Insertion Class ...... Free (Regular Price $195.00) Scrub Uniform ...... Free (Regular Price $30.00) Venipuncture Supplies ...... Free (Regular Price $50.00) Disposable Lab Coat ...... Free (Regular Price $40.00) Infant . Child . Adult CPR-AED ...... Free (Regular Price $79.00) Classroom Instruction ...... Included Hands-on Training ...... Included Skill Assessment Testing ...... Included Total Discount $589.00 Sales Tax (4.712%) $68.42 TOTAL COST OF COURSE (including tax) $1,520.42</p><p>A deposit of between $300.00 to $500.00 must be paid at time of registration. All Forms of Payment Accepted (Cash, Check, Credit & Debit Cards). Note: An additional fee of 3% will be charged to you if pay with Credit or Debit. There is a $30.00 Service Charge for any and all Returned Unpaid Checks. This special tuition can't be used in conjunction with a financial aid. Cancellation/Refund/Rescheduling Policy: Refunds are subject to our refund policy. The refund policy may be viewed on our website at www.caregivertrainingschool.com. On the discretion of the Director of Admission, the student may re-schedule once to the next available training date without a penalty. A letter of request for re-schedule must be received at least 10 business days prior to the start of the scheduled class. If request is made less than 10 business days, the student will be assessed a rescheduling fee of $200.00 (plus tax). Thereafter, any subsequent re-scheduling will incur a fee of $200.00 (plus tax). Class must be completed within six (6) months from the date of the original class date. Changes in the agreement: Any changes must be in writing. Students must mail a written cancellation notice to Caregiver Training School no later than seven business days prior to the start of the scheduled class to be eligible for a refund. Telephone cancellation is not accepted. No refunds will be issued for a student that is dismissed for absenteeism, tardiness, or fails the program. The school reserves the right to re- schedule the class if there is no sufficient number of enrollment, or when an instructor may not be available, and/or any circumstance(s) that is/are beyond the School's control. I agree to make myself available to the new schedule. Agreement is binding: This agreement will be binding only when it has been fully completed, signed and dated by the student and by an authorized representative of the school prior to the start of class.</p><p>Effective date of acceptance: I hereby agree to abide by the conditions set forth herein. I declare that have no criminal record.</p><p>Student and/or Guarantor's Signature Date:</p><p>Office use only:</p><p>School Representative: Date: CTSJan2014</p>