Enroll Now The National Training Institute for Healthcare Technicians 616 Gadsden Hwy Ste. ABirmingham, AL 35235 ENROLLMENT AGREEMENT Student InformationStudent Name: First Name Last Name ServicesMedical AssistantPatient Care TechnicianPhlebotomy TechnicianEKG Technician2-Day Phlebotomy Course3-Day EKG Tech Course1-Day Teeth Whitening TrainingStreet Address: City State / Province / Region ZIP / Postal Code Home/Cell Phone:Work Phone:Email: Social Security Number:Emergency Contact Name: Phone:Relationship to Student: Are you at least 18 years of age? Yes No Are you a U.S. Citizen? Yes No Attestation of High School Graduation or GED*: I understand that a high school diploma or its equivalence is required for admission to TNTI. I hereby certify that I have (select one of the following): A high school diploma A GED HighSchool Name: City/State: Graduation Date: GEDTesting Site: City/State: Graduation Date: If for any reason, this attestation of high school graduation, GED completion or awarded degree is found to be false or untrue, I understand that I will not have met admission requirements for TNTI, Inc., and I will not be considered a regular student and thus subject to immediate dismissal. By signing below, I attest that that information provided above is true and correct and I authorize the to request transcripts or other documentation to confirm my attestation If need be. The tuition above is for the entire program and includes necessary materials and equipment and except the (SKILLS PACK) which I can but at the school; there is no separate charge for books and supplies. The application fee is a one-time fee paid at the time of application. By signing below, I certify that I have received a complete copy of this agreement, and that I have, understand and agree to comply with all of its terms. I also acknowledge that I have received and had an ample opportunity to review a copy of the school’s catalog and I agree to comply with all school disclosures, policies, and rules contained therein. I also understand and agree that this agreement supersedes all prior or contemporaneous verbal or written statements and agreements made by the school or any employee of the school, and that no binding promises, representations or statements have been made to me by the school or any employee of the school regarding any aspect of the education and training I will receive from the school or the prospects for employment or salary upon graduation that are not set forth in writing in this agreement. I further understand and agree that this agreement may not be modified without the written agreement of the school. I hereby certify that all information I provided in my application for admission to the school is complete, accurate and up to date. Once this signed agreement is accepted by the school, I understand that a legally-binding contract is created. My signature indicates that I agree to all of the above terms. Student Signature: Date: MM slash DD slash YYYY Printed Name: NameThis field is for validation purposes and should be left unchanged.