One-Day Class Registration

ONE-DAY CLASS REGISTRATION AND CONSENT FORM
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 THE CLASSES LISTED BELOW ONLY.
Name of person taking the class*

First NameLast Name
Gender*
Birthday*

MonthDayYear
Date
Email (needed to send class link)*
example@example.com
Phone Number*

Area CodePhone Number
Probation Officer or person who told you to take the class (first and last name)*
i.e John Smith
AURORA court clients only: Case # starting with a J (J23232)
ADULT class: (Must be at least 18 years old). Click the box next to the class date you want to attend.

ADULT - Interactive Parenting - ($90) - November 18 - 9:00a - 1:00pADULT - Alternatives to Aggression, Ethics, and Empathy (75) - October 14 - 9:00a - 1:00pADULT - Alternatives to Aggression, Ethics, and Empathy (75) - November 18 - 1:30 - 5:30pADULT - Triple R ($75) - October 14 - 9:00a - 1:00pADULT - Triple R ($75) - November 18- 1:30 - 5:30pADULT - Petty Theft - ($75) - October 14 - 1:30 - 5:30p
NO classes will be offered during the month of DECEMBER.

Please check back here in November for available options in 2024.
Who will be paying for this class: (Select only one)

I am paying for the class. Payment is due today and can be submitted at www.nichange.com/payment.Probation is sending a voucher. Email your probation officer today so they can send a voucher. You are responsible for making sure your probation officer sends the voucher.
IMPORTANT!! READ ALL INSTRUCTIONS AND INFORMATION BELOW BEFORE REGISTERING.

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

* One-day classes are not 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 988, dial 911 or go to the emergency room.

A. I am choosing to complete my one-day class requirement via the online platform called ZOOM.

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 or 1:30pm and runs up to 4 hours. I need to stay for the whole class.

D. I will log in 5 minutes early for class and wait for my teacher to check me into the classroom.

E. I will give 24 hours notice by phone or email (a voicemail is ok with 24 hours notice) to reschedule. If I miss the class I forfeit the full fee/cost of the class. If I have a voucher, I will be responsible for the fee/cost of the class. In order to reschedule I will pay the amount that I owe for the missed class and the cost for the new class in order to reschedule.

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 am not alone, I will be removed from the class.

J. Virtual backgrounds are not allowed.

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

L. I will pay for my class when signing up or I will email my probation officer about a voucher today. 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. I will check my junk/spam folder if I do not see it in my inbox.

For questions or concerns about any of the above, please email us at change@nichange.com. All questions or concerns about the class must be emailed by Thursday at 5pm. The office is closed Friday - Sunday.
Signature of person registering for class*

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ONE-DAY CLASS REGISTRATION AND CONSENT FORM