ACCESS TRAINING, INC.

Transcription

1 WELCOME TO ACCESS TRAINING, INC. Jackson, Mississippi Phone: Fax: APPLICATION PACKET Access Training, Inc. believes that sound education provided by competent staff fully prepares the student with confidence and marketable job skills that will allow the student to choose his/her career. Access today, equals Jobs Tomorrow. We are licensed by the Mississippi Commission on Proprietary School and College License No. C558 Revised

2 Access Training, Inc. Phone: Fax: Toll Free: Please allow us to introduce ourselves. We are Access Training, Inc. located at 1770 Ellis Avenue, Jackson, Mississippi and are licensed by the Mississippi Commission on Proprietary School and College Registration, License No We have been in business since The General purpose of Access Training, Inc. is to provide educational services to the metropolitan area of Jackson, Mississippi and the surrounding area. We specialize in the educational and medical training of certificate courses in Nursing Assistant, Phlebotomy, Dental Assisting and Medical Billing and Coding. All of our courses are at least 100 clock hours. This includes class time, lab and an externship. The Commission on Proprietary Schools and College Registration approves all of our programs. Additionally, the State Department of Health approves our Nursing Assistant program. Upon completion of the Phlebotomy, Clinical Medical Assistant, Pharmacy Technician and Medical Billing & Coding, students are given a National Certification Exam where they become certified in their field. Enclosed is a copy of a course description for each course offered at Access Training, Inc. We would appreciate an opportunity to collaborate with you. Thank you for your time, The staff at Access Training, Inc. 2

3 Access Tr aining, Inc. Available Classes Phlebotomy (DAY) Nursing Assisting (DAY) Dental Assisting (NIGHT) Mon & Wed Mon- Thurs Mon & Wed 9:00 a.m. - 1:00 p.m. 9:00 a.m. - 2:00 p.m. 6:00 pm 10:00 p.m. 9 Week Course 6 Week Course 9 Week Course Phlebotomy (NIGHT) Nursing Assisting (NIGHT) Medical Billing & Coding (Night) Mon & Wed Tues, Wed & Thurs Tues & Thurs 6:00 p.m. - 10:00 p.m. 5:00 p.m. - 10:00 p.m 6:00 pm - 10:00 p.m. 9 Week Course 7 Week Course 8 Month Course Pharmacy Technician (NIGHT) Clinical Medical Assistant (NIGHT) Tues & Thurs Tues & Thurs 6:00 p.m. 10:00 p.m. 6:00 p.m. 10:00 p.m. 12 Week Course 16 Week Course ******************************************************************************** Please submit your application with the following items: Application processing fee of $20.00 cash or money order, (NON-REFUNDABLE) Copy of High School diploma or GED Equivalent or Official Sealed Transcript Copy of Birth Certificate (long or short form) Copy of Drivers License or picture ID Copy of Social Security Card Copy of Form 121 Immunization Record Background Check COE (Certificate of Entitlement for VA students only) Access Training, Inc. is an approved WIA vendor Access Training, Inc is approved for VA students 3

4 Students Background Information Current practices of most employers include a criminal background and/or credit check prior to hire. While a criminal record does not necessarily eliminate you from employment, it is important that you be forthright about such information when completing applications and/or employment agreements. Each conviction will be reviewed with respect to the offense, circumstances, seriousness and the position for which you apply. This information is being provided to you at this time to ensure that you are informed in a timely manner. You may wish to speak with the Job Placement Advisor should you have further questions or concerns. 4

5 BASIC PHLEBOTOMY The program of study is designed to train students in the medical profession of Phlebotomy. Graduates will be able to find employment in the medical facilities, hospitals, laboratories, or other healthcare affiliates requiring the skills of Phlebotomist. Graduates of the program will be qualified to sit for the National Healthcareer Association Examination. This specialized certificate-training program focuses on the primary role of the Phlebotomist, which is to collect blood, safely and without patient discomfort for accurate and reliable test results, as quickly as possible. The student Phlebotomist will be trained in the proper collection techniques and safe handling of blood specimens, using the skills of venipuncture and capillary puncture. As the Phlebotomist play a key role in the healthcare of patients, patient care and communication skills are emphasized. Time management is also incorporated in our Phlebotomy course. Basic Phlebotomy Program Length: 9 weeks Course Outline PHL 101 Basic Phlebotomy PHL 102 Phlebotomy Lab Procedures PHL 201 Phlebotomy Externship Total Clock Hours 24 Hours 24 Hours 120 Hours 168 Hours Course Descriptions PHL 101 Theory This course is designed to introduce the student to the field of Phlebotomy and to present the topics of anatomy and physiology of the circulatory system, safety in Phlebotomy, specimen considerations and patient communication skills. PHL Lab Procedures This course is designed to introduce the student to phlebotomy equipment and to provide the student the opportunity to practice the skills of Phlebotomy with the aid of Vascular access teaching aids. The student will become competent in the various specimen collection procedures and be required to demonstrate infection control techniques, as well as accuracy, speed, and competency of collection procedures. PHL Externship This experience is designed to develop the student's confidence in an actual phlebotomy setting. The student will participate in actual hand-on-training, learning every aspect of the workplace. The student will be expected to demonstrate each of the collection procedures with accuracy and skill. A supervisor will observe and evaluate the student's performance. *Prior to extern entrance, students must present proof of current TB test and hepatitis B. 5

6 NURSING ASSISTANT The Nursing Assistant Program is designed to provide the students with classroom lecture, laboratory practice and clinical training in direct patient care skills. The student will be prepared to sit for the National Nurse Aide Assessment Program exam. After passing the exam Access Training, Inc. will assist the student to obtain a roster number and apply for employment in the ambulatory settings, hospitals, and nursing homes. For students who choose not to take the certification exam, employment assistance will be available upon successful completion of the program s academic requirement, and apply for employment in the ambulatory settings, hospitals and nursing homes. This program emphasizes the importance of nursing assistants as members of the interdisciplinary health care team that plans and provides care to patients. Nursing assistants make valuable contributions to the nursing process that the professional nurse follows in assessing the patient s needs, planning interventions, implementing care and evaluating outcomes. Students who complete the program will be qualified to serve as home health care assistants, and to take the certification exam to become a Nursing Assistant. Nursing Assistant Program Length: 6 Weeks Course Outline NA 101 Theory NA 102 Lab NA 102 Externship Total Clock Hours 45 Hours 30 Hours 40 Hours 115 Hours Course Description NA Theory This course is designed to teach the student to work directly with patients, giving physical care and emotional support. The Nursing Assistant will be able to assist with patient assessment, planning care, promoting patient safety and environmental cleanliness, and promoting personal hygiene and elimination needs. As a result of this course, the student will be able to measure and record vital signs, height, weight and describe the effects of local cold and heat applications. NA 102 Laboratory Procedures This experience is designed to teach the student to recognize and report abnormal changes in body functioning to a supervisor, as well as care for patients when death is imminent. The student will be able to demonstrate skills that incorporate principles of restorative nursing including training the patient in self-care, and using assistive devices in transferring, ambulation, proper turning and positioning, both in the bed and chair. NA Externship This experience is designed for students to utilize skills learned in laboratory settings. Students will provide total patient care under the supervision of an instructor. The student will measure and record vital signs provide care such as bathing, grooming, dressing; and assist with eating and hydration. The student will provide care to the cognitively impaired patient. Upon completion of the clinical rotation, the instructor will evaluate the student's performance. 6

7 DENTAL ASSISTING This program of study is designed to train students in the profession of Dental Assisting. Graduates will be able to find employment in dental offices, HMO clinics, public health institutions, dental supply companies, insurance companies, military dental facilities and dental school clinic affiliates requiring the skills of a trained Dental Assistant. The specialized certificate training program will focus on the primary role of the Dental Assistant. Our goal is to train students to prepare patients for dental treatment, sterilize instruments and assist the dentist at chair side. Students will also learn to manipulate dental materials, perform laboratory duties, execute infection control/universal precaution techniques, maintain inventory and perform receptionist/front office duties. Dental Assistants play a key role in the dental health of patients, dental patient care and communication skills are also emphasized. The Dental Assistant is often the person to seat the patient and explain the treatment, as well as dismiss the patient. Dental Assistant Program Length: 9 Weeks Course Outline DA 101 Basic Dental Assisting Theory DA 102 Dental Assisting Lab Procedures & Front Office DA 103 Dental Assisting Externship Total Hours 44Hours 44 Hours 80 Hours 168 Hours Course Description: DA 101 Basic Dental Assisting Theory This course is designed to introduce the student to dental instrumentation and materials. The student will be given the opportunity to practice the skills of Dental Assisting with the instructor assuming the role of the dentist in a chair side setting. The student will become competent in passing various instruments and treatment modalities, as well as practice mixing dental materials. Infection control procedures and competencies will also be covered in this section. DA 102 Dental Assisting Lab Procedures & Front Office This course is designed to introduce the student to the dental office lab procedures and equipment. The student will be taught skills to perform a variety of laboratory, clinical and office duties. Students will also learn to manage the dental office, including patient scheduling and bookkeeping. DA 103 Dental Assisting Externship This course is designed to develop the student's confidence with experience in an actual dental office setting. The student will participate in providing supervised dental assisting services for a minimum of 80 hours. The student will be expected to demonstrate each of the dental assisting procedures with accuracy and skill. A supervisor and/or instructor will be present on site at all times and will evaluate the student's performance. NOTE: After program completion, the student is eligible to take the Radiation Health and Safety (RHS) and Infection Control (ICE) components of the Certified Dental Assistant (CDA) exam. The General Chair side (GC) component can be taken after the student has worked as a dental assistant for a minimum of 3,500 hours. 7

8 MEDICAL BILLING AND CODING The Medical Billing & Coding Program provides the student with the knowledge and skills needed to be efficient in CPT and ICD-9 medical coding. This program is designed to provide the fundamental requirements of Medical Terminology, knowledge of Anatomy and Physiology as well as proficiency in coding with the use of modifiers. The program will prepare the student to take the National Healthcareer Certification Exam for Billing and Coding. To succeed in medical billing and coding careers, it is recommended that the student have knowledge in keyboarding and computer literacy, and continue to broaden his/her knowledge in this area. Medical Billing & Coding Program Length: 8 Months Course Outline MDT 101 Medical Terminology 48 Hours MAP 102 Medical Anatomy & Physiology 72 Hours MDC 205 Medical Coding ICD-9 84 Hours MDC 207 Medical coding CPT 84 Hours MDB 208 Medical Billing 24 Hours MDC 209 Externship 80 Hours MDC 210 Review 12 Hours Total Clock Hours 404 Hours Course Description: MDT Medical Terminology This course is designed to help the student master the basic language of medicine. Emphasis is placed on spelling and pronunciation of medical terms, definitions and word building by combining prefixes, suffixes and root words. Interpretation of medical reports will be introduced. MAP Medical Anatomy and Physiology This course presents an overview of the structures and functions of the human body. The student will learn to identify skeletal components, internal organs and functions. MDC Medical Coding ICD-9 This course introduces the student to medical coding, which includes diagnostic (ICD-9) coding, as well as legal considerations. The student will learn coding rules and guidelines so that coding can be performed accurately. You may record the lectures if you with and at the instructor s discretion. 8

9 MDC Medical Coding This course introduces the student to medical billing and coding field including legal considerations, diagnostic and procedural coding. An in-depth training in CPT and ICD-9 coding procedures is provided. The student will become efficient in accurately assigning the proper codes to medical/clinical procedures. MDB Medical Billing This course is designed to introduce the student to the practical aspects of medical billing. Emphasis will be placed on insurance claims, HCFA and Medicare/Medicaid billing, utilizing manual simulations. Claims reimbursement, follow-up and collections will be incorporated. MDC Externship This experience is designed to provide the student the opportunity to participate in the actual duties of a medical office. The student is expected to exhibit an understanding of ethical and medio-legal responsibilities related to all aspects of medical billing, accurately code diagnoses and procedures, and record data on insurance forms correctly. A supervisor will observe and evaluate the student's performance. MDC 210 Review This course is designed to provide the student the opportunity to put all experiences obtained throughout the course of study together. The student will be given a review of all subject matters that were taught and will receive answers to any questions that needed clarifications. The student will prepare for the National Healthcareer Certification Exam for Billing and Coding. 9

10 PHARMACY TECHNICIAN This program is a multi-task individual that works along-side a Registered Pharmacist. This program is designed to prepare students to support the licensed pharmacist by assisting with counter dispensing operations and prescription preparation. The curriculum will prepare the student for an entry-level position in pharmacies based in hospitals, retail settings home health care, nursing homes, clinics, and mail order prescription companies. The curriculum also instructs the student on the business aspect of communicating with patients, and customers in a proficient and professional manner. Upon completion of the program the student will be able to sit for the certification exam administered by the Healthcareer Association. Pharmacy Technician Program Length: 12 Weeks Course Outline: Course Description MKB 110-Keyboarding Prerequisite-none This course is designed to help the student reach optimal keyboarding operation and date entry to meet entry level employment opportunities requiring the skill. MDT 101-Medical Terminology Prerequisite-none This course is designed to help the student master the basic language of medicine. Emphasis is placed on spelling and pronunciation of medical terms, definitions, and work building by combining prefixes, suffixes, and root words, Interpretation of medical reports will be introduced. MAP 102-Medical Anatomy and Physiology Co requisite: MDT 101-Medical Terminology This course presents an overview of the structure and functions of the human body. The course focuses in the study if the structure and functions of the human body. Topics include the cells and tissues, integumentary, skeletal, muscular, nervous system, function of the digestive, respiratory, circulatory, urinary, endocrine, and male and female productive systems. 10

11 SPH110-Communication Prerequisite: None This course provides students with skills to improve both written and spoken communication in the workplace setting. PHM 100-Introduction to Pharmacology Prerequisite: None This course presents and overview of the role of the pharmacy technician. The role the pharmacy technician plays in providing patient care. Emphasis is placed on pharmaceutical terms, abbreviations, and symbols used in prescribing and charting medication, dosage forms, routes of administration, patient variables with regard to drug therapy, and systems used in the administration of drugs. PHM101-Pharmacology I Corequisite: PHM 100 This course presents an overview of the study of human disease processes and rational pharmacotherapeutics relating to fluids and nutrients in the following body systems: nervous, endocrine, skeletal, muscular, gastrointestinal, reproductive, and immune. Indications, contraindications, mechanism of action, side effects, dosages, and methods of administration including how these principles can be utilized in pharmacy practice. PHM 102-Parrmacy Law and Ethic Corequisite: PHM 100 and 101 This course provides a survey of federal and state laws governing pharmacy operations. This course develops understanding of the legal and ethical constraints of the pharmacy technician and pharmacist concerning privacy and security if patient confidentiality in various settings governed by the Occupational Safety and Health Administration (OSHA) and Health Insurance Portability Accountability Act (HIPAA) requirements. PHM 103-Nonprescriptive Drugs and Devices Prerequisite: PHM 100, 101, and 102 This course reviews the categories of the over-the counter medications, explains the types and procedures of home monitoring equipment, and provides guidelines for patient counseling. This course will give an explanation of durable and surgical or non-durable medical products. It will also highlight the concepts of vitamins, herbs, and nutritional supplements, and the nontraditional treatment options. PHM 200-Pharmacy Math and Calculations Prerequisite: PHM 100, 101, 102 and 103 This course is designed to instruct the student on proper use of the metric, apothecary, and avoirdupois systems conversation between the systems. Application of formulas, calculations of fractional dosages, and methods of calculating dosages from all drug forms will be studied. Review of calculations dealing with ration and proportion, percentages, ratio strength, reducing and enlarging formulas, and dilution and concentration problems. 11

12 PHM 201-Pharmacology II Prerequisite: PHM 100, 101, 102, 103 This course presents an overview of the study of human disease processes and rational pharmacotherapeutics relating to the cardiovascular, respiratory, renal, hematologic, and dermatologic systems as well as eyes, ears, nose, and throat. Indications, contraindications, mechanism of action, side effects, dosages, and methods of administration including how these principles can be utilized in pharmacy practice. PHM 203-Pharmacy Management Corequisite: PHM 203 This course is designed to discuss the function of pharmacy functions relating to policies and procedures, pharmaceutical purchasing, inventory control, drug recall and returns and maintaining transaction records. The class will explore several retail functions such as payments, billing, oral and written communications, computer date collection, and pharmaceutical merchandising. PHM 300-Pharmacy Externship Prerequisite: PHM 100, 101, 102, 103, 200, 201, 203 This course is designed to allow students who have completed all pharmacy technician courses to work with participating local, registered pharmacists. The advanced student is assigned to a specific pharmacy lab and services 175 hours practicing the responsibilities and duties of the pharmacy technician. PHM 301-Review PrerequisiteA: Successful completion of all courses takes in the curriculum. The summary course is designed to review the skills, and abilities acquired during the didactium. This course will serve to assist the student in preparing for the certification exam with review of critical skills and professional development issues. 12

13 CLINICAL MEDICAL ASSISTANT The clinical Medical Assistant is a multi-skilled allied health professional who performs a wide range of roles in the physicians offices, clinics and other healthcare settings. This program is designed to prepare students to perform administrative duties including; scheduling appointments and procedures; maintaining medical records, handling telephone calls, correspondence, fees and collections, and processing insurance claims. The clinical duties include preparing the patient for e-ray, laboratory and physical examinations, obtaining vital signs, taking medical histories, assisting with examinations and treatments, obtaining specimens, performing routine laboratory procedures, and electrocardiograms. Successful completion of this program entitles graduates to sit for the certification through the Healthcareer Association. Clinical Medical Assistant Program Length: 16 Weeks Course outline MKB 110 Keyboarding MDT 101 Medical Terminology MAP 102 Medical Anatomy and Physiology SPH 110 Communications MED 103 Medical Law and Ethics PHL 101 Basic Phlebotomy PHL 102 Basic Phlebotomy Lab CMA 101 Clinical Office Procedures I EKG 110 Electrocardiogram Theory EKG 111 Electrocardiogram Lab CMA 102 Clinical Office Procedures II MED 112 Pharmacology MET 201 Medical Insurance MET 211 Externship CMA 212 Review Course Description: MKB 110-Keyboarding Prerequisite none This course is designed to help the student reach optimal keyboarding operation and date entry to meet entry level employment opportunities requiring the skill. MDT 101-Medical Terminology Prerequisite none This course is designed to help the student master the basic language of medicine. Emphasis is placed on spelling and pronunciation of medical terms, definitions, and word building by combining prefixes, suffixes, and root words, Interpretation of medical reports will be introduced. 13

14 MAP 102-Medical Anatomy and Physiology Co requisite: MDT 101 Medical Terminology This course presents an overview of the structure and functions of the human body. The course focuses in the study of the structure and functions of the human body. Topics include the cells and tissues, integumentary, skeletal, muscular, nervous system, function of the digestive, respiratory, circulatory, urinary, endocrine, and male and female reproduction systems. SPH 110-Communication Prerequisite: None This course provides students with skills to improve both written and spoken communication in the workplace setting. MED103-Medical Law and Ethics Co requisites: MAP 102 and MDT 101 This course is designed to cover medical law, ethics, and acts; legal relationship of physician and patient; legal responsibilities of medical assistant; and professional liability. PHL 101-Theory Prerequisites: MAP 102, MDT 101, & MED 103 This course is designed to introduce the student to the field of Phlebotomy and to present the topic of anatomy and physiology of the circulatory system, safety in Phlebotomy, specimen considerations and patient communication skills. PHL 102-Lab Prerequisites: MAP 102, MDT 101, &MED 103 This course is designed to introduce the student to phlebotomy equipment and to provide the student the opportunity to practice the skills of Phlebotomy with the aid of vascular access teaching aids. The student will become competent in the various specimen collection procedures and be required to demonstrate. CMA 101-Clinical Office Procedures I Prerequisite: MAP 102, MDT 101, MED 103, PHL 101, and PHL 102 CPR This course is designed to introduce the student to clinical skills emphasizing the importance of being proficient. This course also provides students the opportunities to practice and demonstrate proficiency in simulated settings and the check-offs. EKG 101-Electrocardiogram Theory Prerequisite: CMA 101 This course is designed to introduce the student to the electrocardiogram strips; understanding the theoretical framework of the electrocardiogram wave, lead placement and its components. 14

15 EKG 102-Electrocardiogram Lab Prerequisite: CMA 101 This course is designed to introduce the student to electrocardiogram equipment and to provide the student the opportunity to practice the skills of Electrocardiogram with the aid of cardiovascular teaching aids. The student will become competent in the various aspects of electrocardiogram reading and understand the theoretical framework of the science. CMA 102-Clinical Procedures II Prerequisite: CMA 101, EKG 101, 102 and CPR This course is a continuation of Clinical Procedures I. The course will further the student s knowledge of the more complex activities encountered in the physician s office. The clinical duties include maintaining surgical asepsis, instructing patients in preparation for radiological and sonographic studies, performing EKG s preparing medication as directed by the physician and providing mobility assistance. MED 112- Pharmacology Prerequisite: CMA 101 This course reflects basic theory and clinical information related to drugs, including classifications, source, dosages and measurements, regulatory requirements, and basic principles of drug administration. At all times, safety is emphasized for health professional and patient. MET 201-Medical Insurance Prerequisite: MAP 102; MDT 101 The purpose of this course is to acquaint the student with the different types of insurance, including disability, Worker s compensation, Medicare, Medicaid, Medicare-Medicaid group plans. Practical approach to insurance billing, basic medical and insurance, abbreviations, terminology, ICD-9-CM, and CPT coding will be presented. MET 211-Externship Prerequisite: Successful completion of all courses taken in the curriculum. This course includes supervised experience in medical offices to provide the student with a comprehensive application of administrative and clinical skills. This course is designed to give the student an opportunity to discuss evaluate, and share learning experiences and to strengthen, learning situations brought up in clinical externship. CMA 212-Review Prerequisite: Successful completion of all courses taken in the curriculum. The summary course is designed to review the skills, knowledge, and abilities acquired during the didactium. The course will serve to assist the student in preparing for the certification exam, with review of critical skills, and professional development issues, as well as first aid and cardiopulmonary resuscitation. *Prior to extern entrance, students must present proof of current TB skin test, Hepatitis B, and CPR. 15

16 Application Form Name Maiden Name Address City State Zip Social Security Number - - Home Phone Cell Birthday Age Married Single Divorced Separated Spouse's Name Spouse Employer Address City State Zip Nearest relative not living with you Phone Address City State Zip Do you have reliable transportation? Why did you choose Access Training, Inc? How did you hear about the school? Have you spoken with anyone from this school before? What course are you interested in? Day Night How are you paying for tuition? Education: List all schools attended and dates High School Month Year Diploma GED Month Year Diploma College Month Year Degree College Month Year Degree If you do not have a high school diploma or GED, what was the last grade completed? 16

17 Social Media Contact Information: Facebook Twitter Instagram Employment: List your last two employers, starting with the most current: 1. Employer Name: Start Date End Date Address City State Zip Reason for leaving Supervisor 2. Employer Name: Start Date End Date Address City State Zip Reason for leaving Supervisor ************************************************************************************* Have you ever been convicted of a misdemeanor or felony? Yes No If so, explain When was your last physical? Eye Examination Have you had any serious illnesses, operations or accidents? If yes, please explain Are you presently using drugs for medical treatment or any other reason? If yes, explain I hereby certify that the above information is true and correct: Applicant's Signature Date Licensed and regulated by the Mississippi Commission on Proprietary School and College Registration License #558 17

18 ENROLLMENT AGREEMENT Name Social Security # Address Phone DOB City State Zip The applicant request admission in, a hour course, commencing on, 20. Notice: Any holder of this consumer contract is subject to all claims and defense which the debtor could assert against the seller of goods of service obtained pursuant hereto or with the proceeds hereof. Recovery hereunder by the debtor shall not exceed amounts paid by the debtor hereunder. Truth in Lending Statement: All Prices: All prices for courses are as printed herein. Cost of credit is included in the price cost for the goods and services. This is from the Federal Equal Credit Opportunity Act: Student(s) agree(s) to a delinquency charge on any installment for which payment in full is not received on or before the 10th day after it is scheduled or deferred due date in an amount not to exceed (5%) of the amount of the installment or ($5.00) whichever is less, as permitted by State law. Buyer(s) agree(s) all payments shall be applied to installments in the order in which they fall due, notwithstanding the date received, except payments shall be deemed applied first to current installments in the date received, except payment shall be deemed applied first to current installments in the determination of delinquency charges. Tuition Cost: Registration Fee: Books: Total: Finance Charge: REFUND OF TUITION If a student has paid tuition and fees prior to the starting date of classes and the student does not begin classes or withdraws on the first day of classes, no more than $ of the tuition and processing fees will be retained by Access Training, Inc. If a student withdraws or is discontinued after instruction is begun during the first semester of any program the school may retain no more than: 1. (10%) of the semester's tuition if the termination is during the first week of instruction, or 2. (20%) of the semester's tuition if the termination is during the second week of instruction, or 3. (35%) of the semester's tuition if the termination is during the third week of instruction, or 4. (50%) of the semester's tuition if the termination is during the fourth week of instruction, or 5. (70%) of the semester's tuition if the termination is during the fifth week of instruction, or 6. (100%) of the semester's tuition if the termination occurs after the fifth week of instruction. If a student withdraws or is discontinued after instruction is begun during the second or any subsequent semester of a program the School may retain no more than: 1. (20%) of the semester's tuition if the termination is during the first week of instruction, or 2. (35%) of the semester's tuition if the termination id during the second week of instruction, or 3. (50%) of the semester's tuition if the termination is during the third week of instruction, or 4. (70%) of the semester's tuition if the termination is during the fourth week of instruction, or 5. (100%) of the semester's tuition if the termination occurs after the fourth week of instruction. The undersigned hereby understand and authorizes the school (Access Training, Inc) to pull and review their credit report and to forward that credit report to potential purchasing agents in consideration for purchasing. I recommend the acceptance of this application and agree to guarantee payment of tuition in accordance with the terms and conditions set forth herein. Applicant Signature Date: Name Relationship to Student Address City State Zip By Accepted/Decline by Date (Admission Rep) (School Director) 18

19 PERSONAL REFERENCE These references can be your mother, father, coworker, friend, former boss, uncle, aunt, niece, cousins or any other family member. Name Address City State Zip Phone Number ****************************************************************************** Name Address City State Zip Phone Number ********************************************************************************************* Name Address City State Zip Phone Number ********************************************************************************************* Name Address City State Zip Phone Number 19

20 Access Training, Inc. Media Release I, do hereby give permission to be interviewed, photographed, (Please print your name) and/ or videotaped by Access Training, Inc. or its representatives in connection with an Access Training, production. I understand and agree that the text, photographs, and /or videotapes thereof containing my name, likeness, and voice, including transcripts thereof, may be used in the production of instructional, promotional materials, and for other purposes that Access Training deems appropriate and that such material may be distributed to the public and displayed publicly one or more times and in different formats, including but not limited to websites, cablecasting, broadcasting and other forms of transmission to the public. I also understand that this permission to use the text, photographs, videotapes, and name in such material is not limited in time and that I will not receive any compensation for granting this permission. I understand that Access Training, Inc. has no obligation to use my name, likeness, or voice in the materials it produces, but if Access Training so decides to use them, I acknowledge that it may edit such materials. I hereby waive the right to inspect or approve any use, either in advance or following distribution or display. I hereby unconditionally release Access Training, Inc. and its representatives from any and all claims and demands arising out of the activities under the terms of this agreement. By signing below, I represent that I am of legal age, have full legal capacity, and agree that I will not revoke or deny this agreement at any time. I have read the forgoing and fully understand its contents. Accepted by: Signature: Date: 20