One-Day Class Consent and Registration

IF YOU NEED TO SCHEDULE AN INTAKE, EVALUATION, OR WEEKLY CLASSES, STOP HERE AND CALL 303-231-0090 x1 TO SCHEDULE AN APPOINTMENT. DO NOT FILL OUT THIS FORM. THIS FORM IS FOR ONE-DAY CLASSES ONLY.

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By providing my information and signature below, I am saying that I understand the following:

* One-day classes are not psychotherapy or mental health counseling. No representation of treatment is implied or made as a result of participating in this class. All counseling services offered at National Institute for Change, P.C. are governed under a separate agreement.

* In a crisis or emergency situation, that needs immediate attention, where I am considering seriously harming myself or someone else, I will call the National Suicide Hotline at 800-784-2433, dial 911 or go to a mental health hospital/ER.

A. I am choosing to complete my one-day class requirement via the online platform called ZOOM with National Institute for Change, P.C. ZOOM is an online communication tool allowing for face-to-face video, voice, or text-based chat dialogue. ZOOM is encrypted using the same standards utilized by the US government to protect sensitive information.

(We highly recommend creating an account (if using a computer) https://zoom.us or downloading the app (if using your phone) before your class day so you have some time to familiarize yourself with it if you have not used it before. For a test run of the Zoom tech, please click here: https://zoom.us/test and if you run into any trouble, you may contact them directly at +1-888-799-9666 or info@zoom.us.)

B. Limitations of ZOOM video sessions: Any internet based communication is not 100% guaranteed to be secure/confidential. I agree that National Institute for Change will not be held responsible if any outside party gains access to ZOOM personal or confidential information by bypassing their security measures. Also, technical problems could occur. If the class is disrupted, the teacher will attempt to reconnect within 10 minutes. If reconnection cannot occur, the class will be rescheduled as soon as possible.

C. Class starts at 9:00am and runs for about 4 hours. I need to stay for the whole class.

D. I will log in at 8:55am and wait for my teacher to start class. The classroom closes at 9:05am.

E. I will give 24 hours notice (by phone or email) to reschedule. If I miss the class I forfeit the full amount of the class. If I have a voucher, I will be responsible for the full amount of the class. In order to reschedule I will pay the amount that I owe and the cost for the additional class in order to reschedule. If I don't come to class or if I log in after 9:05am I will need to reschedule and pay the fee.

F. I will have good quality Internet, video, and sound at all times.

G. I will be in a quiet and private space for at least 4 hours. Driving or being in a public place is not allowed.

H. Recording or taking pictures of any part of the class is not allowed.

I. No other person is allowed to attend the class with me. This includes parents, spouses, domestic partners, siblings, or friends. If you are not alone, you will be removed from the class.

J. Virtual backgrounds are not allowed.

K. I will not use drugs or smoking of any type during class.

L. I will pay for my class within 24 hours of signing up. Or I will email my court person about a voucher within 24 hours. Paying for the class is the only way to get the link for the class.

M. The link is emailed to the email address I give when I register. The link is emailed the week of class; no later than two day before the class. I will check my junk/spam folder if I do not see it in my inbox.

N. In order to finish the entire class, I will have to take an online quiz at the end of the day. I need a score of 70% or more to pass and get a certificate. If I don't take the quiz or if I don't pass, I will be need to retake the class and pay for it.

For questions or concerns about any of the above, please email us at change@nichange.com. All questions or concerns about the class should be emailed by Thursday. The office is closed Friday - Sunday.

Name of person taking the class *

First Name Last Name

Birthday *

Date

Email (needed to send class link) *

example@example.com

Phone Number *

Area Code Phone Number

Phone Carrier (To receive a text message with the link for class) *

i.e ATT, Verizon, etc.

AURORA Municipal Court clients only: Case #J blanks

Probation Officer or person who told you to take the class (first and last name) *

i.e John Smith

ADULT class: (Must be at least 19 years old). All classes are $75 unless otherwise noted.

Triple R - June 11 Petty Theft - June 18 Interactive Parenting - June 11 Alternatives to Aggression/Ethics & Victim Empathy (combined) - June 18 Triple R - July 9 Interactive Parenting - July 9 Alternatives to Aggression/Ethics & Victim Empathy (combined) - July 16 Petty Theft - July 16

Who will be paying for this class: (Select only one)

I am paying for the class and will make a payment online within 24 hours online at www.nichange.com/payment. Probation or court person is sending a voucher. Please email your probation officer today to tell them the class date so they can send the voucher. (You are responsible for making sure your probation officer sends the voucher and checking that it has been received).

If signing for a person under the age of 15 years - Name of the Parent/Guardian signing below:

First Name Last Name

Signature of person registering for class or parent ONLY *

Clear

NIC ONE-DAY CLASS PROGRAM CONSENT AND REGISTRATION FORM