St. Luke’s School of Phlebotomy Application

First Name Last Name Phone Number Address City State Zip Code Email Date of Birth Gender

Are you a U.S.A. Citizen? Yes No

Previous St. Luke's Phlebotomy Student Yes No

Current St. Luke's University Health Network Employee Yes No

If yes – what is your employee ID? If yes – what is your current position? If yes – where is your main work location? Previous Work Experience

When you successfully complete the program, what type of employment are you looking to attain? Full Time Part Time Per Diem/Reserve Undecided

Provide Two References with Full Name, Relationship, Phone Number, and Email Address (No Family Members). You will need to provide letters of reference if contacted by our program coordinator.

High School Information:

High School Diploma Type High School Diploma GED

Place Issued:

High School Name High School City High School State High School Country Date Issued

You will need to provide copy of diploma or GED to our program coordinator.

PPC

Program Session Selection: Winter ‘23 Session: January 9, 2023 – April 3, 2023; Tues, Wed, Thurs 10:00am to 3:00pm Summer ‘23 Session: April 17, 2023 – July 10, 2023; Tues, Wed, Thurs 3:00pm to 8:00pm Fall ‘23 Session: August 28, 2023 – November 20, 2023; Tues, Wed, Thurs 10:00am to 3:00pm