Phlebotomy Technician CPT1 Certification Program
Campus: Diablo Medical Training (DMT) - Brentwood
Address: 929 Second St., Suite 18
Brentwood, CA 94513
Phone number: (925) 586-2532 / Fax: 925.513.8230
Enrollment Agreement
Course subject to Article 7 of the CEC
Last Name_____________________ First Name___________________ Student SS#______________
CA Driver Lic.#
Email address
Current address:
City, State, Zip Code
HomePhone___________________WorkPhone___________________MessagePhone______________
Have you ever been convicted of a crime? Yes or No
Emergency Contact Name:
Phone:
A. EDUCATIONAL SERVICE:
Phlebotomy Technician CPT 1
Total Tuition Cost: $2400.00
Total Clock Hours: 130
Total Quarter Credit Hours: 2.0
See Sections C – E below.
B. SPECIFIC TIME OF CLASSES: (Circle) M T W TH FR Sat Sun Start Time:
End Time:
Didactic/Practical Start Date: ___________ Didactic/Practical End Date: ______________
Externship Start Date*: ___________ Externship End Date*: ______________
*Note: Externship hours (80) are scheduled after the student receives a passing grade on the course Final
Examination. Externship hours and locations are subject to hours available from contracted externship
partners. Externship is normally completed within 60 calendar days of the CPT 1 final examination, unless a
written request for delay is submitted by the student at least one week prior to the scheduled externship
start date.
C. TOTAL INSTITUTIONAL FEES: Registration Fee $75.00 (non-refundable); Tuition $2400.00 (refundable);
STRF fee $0.00 (non-refundable); Liability Insurance $50.00; Supplies and Materials $125.00:
Total Charges for Period of Attendance = $2650.00
D. REQUIRED OUT OF POCKET FEES (not paid directly to Diablo Medical Training): Uniforms $30.00
(non-refundable); BLS $55.00 (non-refundable); Drug Screen $35.00 (non-refundable); Books $88.00 (Eligible
for Buy Back); California State Application Fee $100.00 (non-refundable):
Total Estimated Out of Pocket Expenses = $308.00
E. OPTIONAL FEE: National Certification Exam $90.00 (non-refundable, non-DMT)
(This exam is required by State of California for Certification, but not Diablo Medical Training.)
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Tuition and fee refunds are available if the student withdraws from the program, but prorated upon program
completion. No refund is available after the student has completed 60% of the program. Students considering
withdrawal from the program are requested to submit withdrawal paperwork prior to beginning the
Externship portion of the program. The last day to qualify for a pro-rated refund is prior to the second day of
scheduled Externship. Refer to refund information in your Student Catalog and beginning on Page 5 of this
agreement.
ESTIMATED SCHEDULE OF TOTAL CHARGES FOR THE ENTIRE EDUCATION PROGRAM: $2958.00**
**Includes additional out-of-pocket estimates and does not include option expenses listed in Sec. E
YOU ARE RESPONSIBLE FOR THIS AMOUNT. IF YOU GET A STUDENT LOAN, YOU ARE RESPONSIBLE FOR
REPAYING THE LOAN AMOUNT PLUS ANY INTEREST, LESS THE AMOUNT OF ANY REFUND THAT IS DUE. IF YOU
ARE SELECTING A PAYMENT PLAN TO PAY FOR TUITION, PLEASE SEE THE SEPARATE INSTALLMENT NOTE IN
THE BACK OF THIS ENROLLMENT AGREEMENT.
Notice for Students Receiving Federal or State Student Financial Aid:
(1) If the student defaults on the student loan obligation, the federal or state government or a loan
guarantee agency may take action against the student, including applying and income tax refund to
which the person is entitled to reduce the balance owed on the loan.
(2) The student may not be eligible for any other federal student financial aid at another institution or
other government financial assistance at another institution until the loan is repaid.
(3) If a refund is due to the student, the student is entitled to a refund of the money not paid from federal
financial aid funds.
If you cancel, withdraw or are terminated from training, your financial obligation and refund (if any) will be
under the conditions described in the "Cancellation" and "Withdrawal" sections that are included in this
agreement.
STRF (Student Tuition Recovery Fund)
STRF is a state requirement that a student who pays his or her tuition is required to pay a state imposed
assessment for the student tuition recovery fund. All students that are residents of California that pay their
tuition either by cash, guaranteed student loans, or personal loans must participate in the Student Tuition'
Recovery Fund (STRF). The rate for your program, beginning January 1, 2015 is zero ($0). The Non-Refundable
STRF charge for your program will be based on the charge of $0.00 for $1,000.00 in tuition charges rounded
to the nearest $1,000.00. The STRF rate is subject to change based upon the balance in the STRF account.
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Statute requires the Bureau begin collecting if the balance falls below $20 million ($20,000,000.00) and caps
the account at $25 million ($25,000,000.00). The STRF was established by the Legislature to protect any
student who attends a private postsecondary institution from losing money if you prepaid tuition and suffered
a financial loss as a result of the school closing. You do not qualify by failing to live up to the school's
enrollment agreement or refusing to pay a court judgment. The following is a description of the students'
Rights and Responsibilities with respect to the Student Tuition Recovery Fund:
You must pay the state-imposed assessment for the Student Tuition Recovery Fund (STRF) it all of the
following applies to you:
 You are a student in an educational program, who is a California resident, or are enrolled in a
residency program, and prepay all or part of your tuition either by cash, guaranteed student loans, or
personal loans, and
 Your total charges are not paid by any third-party payer such as an employer, government program or
other payer unless you have a separate agreement to repay the third party.
 You are not eligible for protection from the STRF and you are not required to pay the STRF assessment,
if either of the following applies:
o You are not a California resident, or are not enrolled in a residency program, or
o Your total charges are paid by a third party, such as an employer, government program or
other payer, and you have no separate agreement to repay the third party."
"The State of California created the Student Tuition Recovery Fund (STRF) to relieve or mitigate economic
losses suffered by students in educational programs who are California residents, or are enrolled in a
residency program attending certain schools regulated by the Bureau for Private Postsecondary and
Vocational Education.”
You may be eligible for STRF if you are a California resident or are enrolled in a residency program, prepaid
tuition, paid the STRF assessment, and suffered an economic loss as a result of any of the following:
1. The school closed before the course of instruction was completed.
2. The school's failure to pay refunds or charges on behalf of a student to a third party for license fees
or any other purpose, or to provide equipment or materials for which a charge was collected within
180 days before the closure of the school.
3. The school's failure to pay or reimburse loan proceeds under a federally guaranteed student loan
program as required by law or to pay or reimburse proceeds received by the school prior to closure in
excess of tuition and other costs.
4. There was a material failure to comply with the Act or this Division within 30 days before the school
closed or, if the material failure began earlier than 30 days prior to closure, the period determined by
the Bureau.
5. "An inability after diligent efforts to prosecute, prove, and collect on a judgment against the institution
for a violation of the Act."
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However, no claim can be paid to any student without a social security number or a taxpayer identification
number.
To qualify for STRF reimbursement you must file a STRF application within one year of receiving notice from
BPPE that the school is closed. IF you do not receive notice from BPPE, you have four years from the date of
closure to file a STRF application. If a judgment is obtained you must file a STRF application within two years
of the final judgment. It is important that you keep copies of the enrollment agreement, receipts or any other
information that documents the monies paid to the school. Any questions regarding the STRF may be directed
to: www.bppe.ca.gov. Call toll free 1-888-370-7589 or fax to 1-916-263-1897; BPPE, 2535 Capitol Oaks Drive,
Suite 400, Sacramento, California, 95833.
THE TERMS AND CONDITIONS OF THIS AGREEMENT ARE NOT SUBJECT TO AMENDMENT OR MODIFICATION BY
ORAL AGREEMENT. I, THE UNDERSIGNED PURCHASER OF THE PROGRAM OF TRAINING, HAVE READ,
UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS CONTAINED HEREIN AND WITH MY SIGNATURE
I CERTIFY HAVING RECEIVED AN EXACT COPY OF THIS AGREEMENT AND A COPY OF THE SCHOOL CATALOG,
AND FURTHER ACKNOWLEDGE THAT NO VERBAL STATEMENTS HAVE BEEN MADE CONTRARY TO WHAT IS
CONTAINED IN THIS APPLICATION. THE ENROLLMENT AGREEMENT IS A LEGALLY BINDING INSTRUMENT
WHEN SIGNED BY THE STUDENT AND ACCEPTED BY THE SCHOOL.
Student Initials ( )
I agree to attend all classes as scheduled, to perform all duties required by the School and abide by the rules
and regulations of the School in accordance with the policies set forth in the current School catalog. I may be
terminated from the School under the following conditions: failure to maintain passing grades; misconduct
and I or failure to abide by the rules and regulations of the School; absences in excess of the maximum set
forth by the School; failure to meet financial obligations to the School. Upon successfully completing all
requirements of the program, I will receive a Course Completion Certificate. In order to graduate you must
successfully pass the class. The school does not school offer formal Placement Assistance. The school cannot,
in anyway, guarantee employment after the student has successfully completed the program of study. I have
received a tour of the school facilities and inspection of equipment where training and services are provided.
Student Initials ( )
Prior to signing this enrollment agreement, you must be given a Catalog or Brochure and a School Performance
Fact Sheet, which you are encouraged to review prior to signing this agreement. These documents contain
important policies and performance data for this institution. This institution is required to have you sign and
date the information included in the School Performance Fact Sheet relating to completion rates, placement
rates, license examination passage rates and salaries or wages prior to signing this agreement.
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I certify that I have received the catalog, School Performance Fact Sheet, and information regarding
completion rates, placement rates, license examination passage rates, and salary or wage information, and the
most recent three-year cohort default rate, if applicable, included in the School Performance Fact Sheet, and
have signed, initialed, and dated the information provided in the School Performance Fact Sheet.
Student Initials ( )
I further acknowledge that I understand and agreed to my rights and responsibilities, and that the
institution's cancellation and refund policies have been clearly explained to me.
Student Initials ( )
Student certifies that he/she has received each of the following documents initialed below and was allowed
sufficient time to read and understand them: (Please initial for each document received.)
( ) Notice of Cancellation
( ) Copy of this Agreement
( ) Current School Course Catalog or Brochure
( ) Tuition and Fee Information
( ) School Performance Fact Sheet
( ) Notice of Student Rights
( ) Student Disclosure Form
( ) Pass/Fail Comp. Evaluation
TOTAL CHARGES FOR CURRENT PERIOD OF ATTENDANCE REGISTRATION FEE, $75.00, DUE AT TIME OF
ENROLLMENT. TOTAL DUE DIABLO MEDICAL TRAINING FOR PHLEBOTOMY TECHNICIAN CPT 1 PROGRAM:
$2650.00. ESTIMATED REQUIRED ADDITIONAL OUT OF POCKET EXPENSES: $308.00. TOTAL DUE FOR ENTIRE
PROGRAM: $2958.00. See Pages 1 - 2 for details.
I understand that this is a legally binding contract. My signature below certifies that I have read,
understood, and agreed to my rights and responsibilities, and that the institution's cancellation and refund
polices have been clearly explained to me.
Signed:
______________________ Print Name: ______________________________
Signature of Applicant
Date signed
_________________
Accepted by: ____________________
School Representative
______ _____
Title
______
Acceptance Date
Any questions a student may have regarding this enrollment agreement that have not been satisfactorily
answered by the institution may be directed to the Bureau for Private Postsecondary Education at
Address: 2535 Capitol Oak Drive, Suite 400, Sacramento, CA. 95833
PO box 980818, West Sacramento, CA. 95798-0818;
Web site address: www.bppe.ca.gov;
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Telephone and Fax #’s: (888) 370-7589 or fax (916) 263-1897
(916) 431-6959 or fax (916) 263-1897
BE SURE TO READ ALL PAGES OF THIS AGREEMENT. IT IS PART OF YOUR CONTRACT WITH THE SCHOOL.
Notice of Student's Right to Cancel
1. You have the right to cancel this agreement, including any equipment or other goods and services included
in the agreement, and receive a full refund (less a deposit or application fee not to exceed $100) through
attendance of the first class session, or the seventh day after enrollment, whichever is later.
2. Cancellations due to rejection of application, program cancellation, no show/non starts, cancellation by
student during the cancellation period, will receive a full refund (less a deposit or application fee not to
exceed $125) within 30 days of cancellation date.
3. Your cancellation takes effect when you give written Notice of Cancellation to this school at the address
above. Any written expression that you wish not to be bound by this agreement will serve as a Notice of
Cancellation of this agreement. Read the Notice of Cancellation form provided to you for an explanation of
your cancellation rights and responsibilities. If you have lost your Notice of Cancellation form, ask the
school for a sample copy.
4. You are due a complete refund within 30 days after the school receives a valid Notice of Cancellation.
5. After the end of the cancellation period, you also have the right to stop school at any time; and you have
the right to receive a refund for the part of the course not taken.
6. Cancellation shall occur 'when the student provides a written notice of cancellation to the address of
Diablo Medical Training: 925 Second Street Suite 16, Brentwood, California, Attn: Campus Director. This
can be done by mail, hand delivery, or fax (925) 513-8230.
7. The written notice of cancellation, if sent by mail, is effective when deposited in the mail properly
addressed with proper postage.
WITHDRAWAL: Withdrawing from a Course
Students have the right to withdraw from a program of instruction until the 60% point of the course and
receive at least a partial refund. Students are obligated to pay only for education services rendered and any
unreturned equipment until the 60 percent point of the course, as measured in hours, no which will he
possible. If the student has received federal student financial aid funds, the student is entitled to a refund
from federal student program funds. Diablo Medical Training’s certification course does not currently
participate in federal student financial aid programs.
The refund shall be calculated by (a) deducting a registration fee not exceeding $100 from the total tuition
charge; (b) dividing this figure by the number of hours in the program; (c) the quotient is the hourly charge
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for the program; (d) the amount owed by the student for purposes of calculating a refund is derived by
multiplying the total hours attended by the hourly charge for instruction; (e) the refund would be any
amount in excess of the figure derived in step (f) that was paid by the student; and (g) the refund amount
shall be adjusted for unreturned equipment. If a separate charge for equipment is specified in the
agreement, and the student actually obtains the equipment, and the student returns that equipment in
good condition allowing for reasonable wear and tear, within 30 days following the date of the student's
withdrawal, the institution shall refund the charge for the equipment paid by the student. If the student fails
to return that equipment in good condition, allowing for reasonable wear and tear, within 30 days following
the date of the student’s withdrawal, DMT may offset against the refund calculated the documented cost to
the institution of that equipment. The student is liable for the amount, if any, by which the documented cost
for equipment exceeds the prorated refund amount. Equipment cannot be returned in good condition if the
equipment cannot be reused because of health and sanitary reasons and this fact is clearly and conspicuously
disclosed in the agreement. If any portion of the tuition was paid from the proceeds of a loan or third party,
the refund shall be sent to the lender, third party or, if appropriate, to the state or federal agency that
guaranteed or reinsured the loan. Any amount of the refund in excess of the unpaid balance of the loan shall
be first used to repay any student financial aid programs from which the student received benefits, in
proportion to the amount of the benefits received, and any remaining amount shall be paid to the student.
How Does Diablo Medical Training Calculate Refunds?
Total program charge - Registration fee = Total program cost
Total program cost DIVIDED program hours = Program fee per hour.
Per hour program fee x hours attended = Total program charge
Total program cost - Total program charge = Refund
(The hourly program fee shall be multiplied by hours attended by student minus program charge equals
refund.)
IF THE AMOUNT THAT THE STUDENT PAID IS MORE THAN THE AMOUNT THAT THE STUDENT OWES FOR THE
TIME ATTENDED, THEN A REFUND WILL BE MADE WITHIN 30 DAYS OF THE DATE OF DETERMINATION OF
WITHDRAWAL. IF THE AMOUNT THAT THE STUDENT OWES IS MORE THAN THE AMOUNT THAT THE STUDENT
HAS ALREADY PAID, THEN THE STUDENT WILL HAVE TO ARRANGE TO PAY IT.
Hypothetical Refund Example
For example, if a student enrolls in a 100 hour program and withdraws after receiving 35 hours of
instruction, and if the student paid a $75.00 registration fee and $2,000 tuition, the school would deduct
the $75.00 registration fee from the amount received, divide the remaining $2,000 by the number of hours
in the program (2000/ 100 = 20) and multiply that hourly amount times the number of hours received by the
student (35 x 20 =$700.) The amount paid; in excess of that amount would be the amount of the refund.
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($2,000 - $700 = $1,300) Refund Amount. In addition, the refund would include any amount paid for
equipment, which is subsequently returned in good condition. If you attend class and drop before payment is
made, you will be responsible for tuition accrued up to the date formal withdrawal notice is given.
If the school cancels or discontinues a course or educational program, the school will make a full refund of all
charges. Refunds will be paid within 30 clays of cancellation or withdrawal.
Payment of Refunds
Refunds are made within 30 days following the date upon which the student's withdrawal has been
determined. Pre-contract Disclosure: If the student obtains a loan to pay for the course of instruction, the
student will have the responsibility to repay the full amount of the loan plus interest, less the amount of any
refund.
NOTICE CONCERNING TRANSFERABILITY OF CREDITS AND CREDENTIALS EARNED
AT DIABO MEDICAL TRAINING
Transfer Credit/Credit Evaluation
The transferability of credits you earn at Diablo Medical Training is at the complete discretion of and
institution to which you may seek to transfer. Acceptance of the CPT 1 certificate you earn in Phlebotomy
Technician Training CPT 1 Program is also at the complete discretion of the institution to which you may seek
to transfer. If the CPT 1 certificate that you earn at this institution are not accepted at the institution to which
you seek to transfer, you may be required to repeat some or all of your coursework at that institution. For this
reason you should make certain that your attendance at this institution will meet your education goals. This
may include contacting an institution to which you may seek transfer after attending Diablo Medical Training
to determine if you CPT 1 certificate will transfer.
Diablo Medical Training allows for the transfer of credits earned at another institution if that institution is
Nationally or Regionally accredited by an agency recognized by either the U. S. Department of Education
or the Council for Higher Education, and if the previous credits earned are comparable to those offered in the
institution's program in which the student seeks to enroll. All considered credits must have been earned
within the last three years, and be of "C" average or above. Diablo Medical Training will allow no more than
50% of any program to be credited by transferring credits from another institution. Course credits for
advanced placement through outside examination may be considered, but are generally not accepted. There is
no fee for the evaluation or the granting of transfer of credit.
A written request for credit transfer must be made to the Campus Director at least two weeks prior to the
start of class, in order to allow Diablo Medical Training adequate time for evaluation. Requests made with less
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than 2 weeks prior notice will not be evaluated. The request must include an official transcript from the
student's prior institution, and course descriptions in the form of syllabi or institutional catalogs which
include clock and/or credit hours. A decision will be made within one week of receipt of the requisite
documents, and the student will be advised by mail or email. Any appeal to the institution's decision must be
made in writing and submitted to the Campus Director. The subsequent decision will be final.
Any reduction in tuition resulting from the transfer of credits will be based on the per hour cost of training
for the program times the number of clock hours of the institution's comparable program for which the
student is being given credit. The student is allowed and encouraged to sit, free of charge, for purposes of
review, any portions of the program for which she/he has been given credit, as long as classroom space is
available. If an enrollment agreement had been signed by the student prior to a request for credit transfer,
and credit is accepted, a new enrollment agreement must be signed to include any changes to the amount
of financial obligation of the student due to the transfer of credit. Diablo Medical Training makes no
guarantee of transferability of credits to another institution, but will assist the student wishing to "transfer
out" by providing guidance, and providing official transcripts, syllabi, course outlines, or institutional
catalogs as requested, at no charge to the student. At this time the Institution does not have any written
articulation agreements with other proprietary, post-secondary or other institutions of higher learning.
Enrollment Agreement-Installment and Disclosure Statement
Date ____________________
As payment for tuition at Diablo Medical Training, I promise to pay the school, the sum of
$___________________ for the following _________________Installments, see you Disclosure Statement –
Payment Schedule below.
Sign here
_________________ Date _________________________
Print Name _______________________________________________
Address______________________________________________________________________________
City_________________________________________ State ________________ Zip ______________
Home Tel: (
) ___________________________ Work Tel: (
) _____________________________
Social Security #____________-____________-_____________
The terms and conditions contained in the Enrollment Agreement and the “Disclosure Statement,” which is
incorporated herein by reference as though set forth in full. Should default be made in any payment when
due, the whole sum shall immediately become due and payable.
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Be signing below the buyer acknowledge receipt of a completed and true copy of his installment contract and
jointly and severally agrees to all of the terms and conditions.
Method of Payment accepted by Diablo Medical Training is cash, credit card, personal/business check, money
order, and ATM/Debit card.
DISCLOSURE STATEMENT-YOUR PAYMENT SCHEDULE WILL BE:
Number of payments _________ Amount of each payment _________ weekly/monthly/other______
Beginning on __________________________and ending on ______________________________.
LATE CHARGES: if any payment is more than 10 days late you will be charged $50.00 late fee.
PREPAYMENT: Prepayment is allowed at any time.
NOTICE TO BUYER: (1) Do not sign this agreement before you read it or if it contains any blank spaces to be
filled. (2) You are entitled to a completely filled-in copy of this agreement. (3) You can prepay the full amount
due under this agreement at any time.
Any questions a student may have regarding this enrollment agreement that have not been satisfactorily
answered by the institution may be directed to the Bureau for Private Postsecondary Education at
Address: 2535 Capitol Oak Drive, Suite 400, Sacramento, CA. 95833
PO box 980818, West Sacramento, CA. 95798-0818;
Web site address: www.bppe.ca.gov;
Telephone and Fax #’s: (888) 370-7589 or fax (916) 263-1897
(916) 431-6959 or fax (916) 263-1897
A student or any member of the public may file a complaint about this institution with the Bureau for Private
Postsecondary Education by calling (888) 370-7589 toll-free or by completing a complaint form, which can be
obtained on the bureau’s internet web site www.bppe.ca.gov.
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