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A drug screen will be required prior to the start of externship/clinical. Students must obtain the Hepatitis Vaccination Series and

satisfy a criminal background check. Individuals who have been convicted, pleaded guilty or pleaded no contest to certain felony crimes may be unable to attend clinical training or obtain employment in a licensed health care facility in Mississippi. In addition, other felony and some misdemeanor charges may disqualify the student from participating in clinical experiences. This includes, but is not limited to most felony charges, patterns of criminal charges, criminal charges within the past five years, no dispensation of charges, and pending charges.


By signing below, I agree that all the above statements are true and agree to abide by the conditions of
this program and the rules and regulations of Grace Phlebotomy Academy. I understand if accepted as a student it will be made on the basis of the information provided on this application. I agree to notify the administer, if circumstances or requirements for this program may disqualify my participation. As of the date of my registration, I know of no reason why I should not be accepted as a student of Grace Phlebotomy Academy.

Also, I agree to abide by the Code of Conduct Policy as indicated below:
Rational and respectable conduct and a professional image is expected at all times.

Obscene language, rough housing, and insubordination will not be tolerated.

The possession and use of alcoholic beverages, drugs or tobacco by students is prohibited during all functions.


Because of the benefits to be derived from this program, I expressly waive all claims against Grace Phlebotomy Academy, its Board of Directors, volunteers, and representatives against any accidents and or illnesses that may occur during any scheduled training sessions, events and/or other activities.

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