Northeast Medical Institute LLC SIS and LMS Portal.Powered By Classe365

Personal Details

First Name^*

Last Name^*

Email^*

Gender^*

Female Male

Telephone Number^*

Date of Birth^*

Example: 10-30-1980

SSN^*

Admission Date

This is the date you fill out this paperwork

PPD or TB Test

THIS IS NOT REQUIRED TO REGISTER BUT WILL BE REQUIRED TO COME INTO CLASS FOR LAB/CLINICAL.

Address

Address^*

City ^*

State^*

Zip Code^*

Emergency Contact

Emergency Contact Name^*

Emergency Contact Telephone number^*

Emergency Contact Relationship^*

Program of Interest

Class^*

Day or Evening^*

Location^*

Start Date^*

Check on website calendar

Graduation Date^*

Max Capacity Policy^*

I understand the Max Capacity Policy.

If the class you choose is full due to our max capacity limits you will be added to the next available class at that location. Example; If July 5 Stamford CNA Daytime is full and you registered for this class you would automatically be put into the next Stamford CNA Daytime class. There are NO ENROLLMENT REFUNDS if you choose a class that is already full and have to be assigned to the next class.

CNA Scrub Size( Unisex Sizing)

Small Medium Large X-Large 2X Large

Only Check if you are in the CNA or PCT Program. These can not be exchanged or returned.

Lab Coat Size ( Unisex Sizing)

Small Medium Large X-Large

Only Check if you are in the Phlebotomy or PCT Program. These can not be exchanged or returned.

Refresher CNA Course Only

Yes

This is only for students who have completed a CNA course in the past 2 years and have proof to show Northeast Medical. If you do not show proof upon registration you may not be accepted.

Patient Care Tech

Yes

This is for students who are interested in doing all 3 courses; CNA, Phlebotomy and EKG. These three courses will allow you to take the Patient Care Tech Exam.

CNA Online Lab/Clinical Acknowledgment ^*

I understand that I will not be refunded my registration because I can not make it to the CNA Labs/Clinical which I understand can occur at minimum from 1-3 weeks after the online class is finished.

CNA Online Labs/Clinical classes may start between 1-3 weeks minimum after the 2 week period of the online course.

CNA State Testing Acknowledgment^*

I acknowledge and understand

I acknowledge and understand that Northeast Medical Institute DOES NOT run CNA State Testing, but the Middlebury and Woodbridge sites are used by Prometric to administer the exam. WE DO NOT CONTROL THE SCHEDULE OF THE EXAMS!

Background Check & Drug Testing^*

I understand and will allow Northeast Medical Institute LLC to perform a background check for clinical requirements. If the background check comes back with any misdemeanors or felonies I understand that I may not be able to finish the program due to clinical requirements. I also understand that depending on the clinical location and requirements of your clinical that I may have to have a drug test performed. If this were to come back negative or your background check shows any felonies or misdemeanors you may not be able to complete the program. I understand there will be no refunds.

Background Check & Drug Testing Acknowledgement

Phlebotomy Graduation Requirement Acknowledgment^*

I understand/acknowledge these requirements and know that I will not get a refund if I do not follow them.

Applicants understand that there are 30 venipunctures and 10 capillary sticks required for the course. This does NOT mean they must bring in 30 volunteers. Ideally, students will be able to locate 4-6 volunteers to assist them with meeting this requirement. They must also volunteer themselves in order to assist their classmates in completing the required sticks. They must complete these stick requirements, as well as the ones listed in the Northeast Medical Institute School Catalog, in order to graduate. They cannot, and will not, receive a diploma, or the NHA credential, until all are completed.

Labs must be completed at the location you select when you register and can only be changed with approval from administration. If there are less than four students enrolled at the campus you select, you will be assigned to the next closest campus to complete your sticks.

Phlebotomy Students will need to provide the following 1 week prior to the start of their class or they may not be let into lab :

Negative PPD ( Taken within last 12 months)
Hep B Form ( You can decline getting the Hep B on the form)

NHA Requires that you either have a high school diploma or GED. If you do not have either of these you will need to show you are going to be getting this within a year of taking the exam with them. You are eligible to take the Phlebotomy course and graduate from our school with a certificate of completion without a GED or High school Diploma.

Enrollment Form Amendment Acknowledgment^*

I understand/acknowledge these requirements

If I need to extend my course and amend the original enrollment agreement I understand that there will be a $25 per day reschedule fee. No course can be rescheduled more than 2 months past the original end date. All prior payment obligations must be paid in full before amendment is approved.The reschedule fee must be paid upon approval of amendment.

Credit/Debit Card Authorization Statement- Phlebotomy Training Requirement Only^*

I understand/acknowledge these requirements

Credit/Debit Card Authorization Statement- Phlebotomy Training Requirement Only

In order to fulfill the requirements for the Phlebotomy Training Course at Northeast Medical Institute, I hereby agree to provide my credit/debit card information to be securely held on file.

I understand that this information will only be used in the following circumstances:

To cover any outstanding fees, charges, or expenses related to the course, including but not limited to tuition, materials, and certification fees.

In the event of a cancellation or withdrawal from the course within the specified timeframe outlined in the school's policies, to process any applicable cancellation fees.

To address any damages or loss of equipment provided during the course, as outlined in the school's policies.

I acknowledge that my credit/debit card information will be stored securely and will only be accessed by authorized personnel for the purposes mentioned above. I further understand that my card will not be charged without my prior consent, except as stated in this agreement.

By providing my credit/debit card information on our credit card authorization form, I confirm that I am the authorized cardholder and that I have read and understood the terms and conditions outlined in this agreement.

Payment Plan/Financing

Payment Plan

Would you like to be contacted about our payment plan? We require all students to be fully paid by the second Monday of class. YOU MUST PAY FOR THE REGISTRATION FEE IN ORDER FOR YOUR REGISTRATION TO BE VALID. PLEASE READ THE SCHOOL CATALOG TO GO OVER OUR PAYMENT PLAN WHICH WE WILL AUTOMATICALLY ADD TO YOUR ACCOUNT IF YOU CLICK YES BELOW.

AfterPay

Need more time to pay for your class? We offer AFTERPAY which allows you to break payments up for 8 weeks. You will be charged a 6% processing fees but there is NO CREDIT Checks.

Program Pricing^*

Yes I understand the pricing and will read over the School Catalog. All of the pricing above does not include the 2.7% fee and I understand that.

Online Self Paced CNA
Tuition $1,200
Supplies (Stethoscope & BP Cuff & Gait Belt) $50
Scrubs 1st set free
Registration Fee: $350
Program Total: $1,600

Does Not Include (Will be added to the invoice):
State Exam Prometric- $118 ( Not Paid to the School)
HPSO Insurance -$25
2nd Set of Scrubs - $25
Background Check – $12.95

Phlebotomy
Tuition $1,160
Lab Tech Coat included free
Supplies $90
Books $60
Registration Fee $250
Program Total: $1,560

Does Not Include(Will be added to the invoice):
NHA Exam - $115 ( Paid to NHA)
HPSO Insurance -$25

EKG
Tuition $250
Supplies $50
Registration Fee $200 (non-refundable)
Program Total: $500

Does not include:
NHA PCT Exam- $155 (Paid to NHA)

PATIENT CARE TECH (PCT) PRICING IS JUST ALL 3 COURSE PRICES COMBINED

Sacred Heart University Student Discount

Please Upload your current SHU ID to receive a discount.

Registration Payment Required for those who are not State Funded

Refund Acknowledgment^*

I understand that I will not be given a refund for the registration fee under any circumstance and that if I withdraw less than 20 days prior to the start of my class any additional money paid towards my enrollment will also not be refunded.

A student may cancel his/her Enrollment Agreement 20 days before the first day of the program without any tuition and fee charges, except for the Non-Refundable Registration Fee. No refunds will be provided if less than 20 days remain prior to the start of the class. A student may also cancel the Enrollment Agreement without penalty or obligation by the period deadline ( 20 days before the class start date). The student will receive a full tuition refund 20 days prior the start of a course (except for the non-refundable Registration Fee). Refundable tuition is defined as the total course tuition excluding the Non-Refundable Registration Fee.

If a student registers for a course that is already full they will NOT RECEIVE A REFUND. You will be automatically put in the next available class at that campus. Please READ THE WEBSITE and NOTE that this is a First Come First Serve.

Fees

Other Fees
You need to choose atleast 1 in order to complete the first portion of your registration.
	CNA Registration Fee Only- Self Paced Online	350
	Phlebotomy Registration Fee Only	256.75
	EKG Registration Only	200
	Total	0.00

Check box here to sign

Step 1)

Please fill out the School Enrollment Agreement Form sent to you by email after you click submit below. ( CHECK YOUR SPAM AND JUNK)

Step 2)

Please read the School Catalog by Clicking on the link below

Click Here

Payment Options :

If you want to just hold your spot in the class you must pay for the Enrollment Fee Only

I HAVE READ AND UNDERSTAND THIS ENROLLMENT FORM ,THE SCHOOL CATALOG, AND THE COVID 19 MODIFICATION FORM.
I UNDERSTAND THAT THIS DOCUMENT IS A LEGALLY BINDING DOCUMENT AND ALL PAYMENTS MUST FOLLOW OUR PAYMENT SCHEDULE REQUIREMENTS.
I ACKNOWLEDGED RECEIPT OF AN EXACT COPY OF THIS ENROLLMENT AGREEMENT AND A COPY OF THE SCHOOL CATALOG.
I UNDERSTAND THAT THIS ENROLLMENT FORM SHALL NOT BE DEEMED COMPLETED AND VALID UNTIL THE AUTHORIZED SCHOOL OFFICIAL HAS SIGNED AND THE STUDENT HAS SIGNED AND RECEIVED A COPY OF THE ENROLLMENT AGREEMENT.
IF THE STUDENT IS A MINOR THEY MUST HAVE THIS FORM SIGNED BY THEIR LEGAL GUARDIAN.

BY Clicking I Agree you are digitally signing up agree with all the terms, conditions, and policies listed in the Enrollment Agreement Above.

Please accept the terms & conditions to submit this form.