One-Day Class Consent and Registration

IF YOU NEED TO SCHEDULE AN INTAKE, EVAUALTION, 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 acknowledge and understand the following:

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 promptly at 9:00 am and runs approximately 4 hours. The full length of the class will be determined, by the teacher, the day of class as it varies according to class size. No guarantee of early dismissal can be made so, if I cannot attend the full length of the class, I will email the office to reschedule.

D. I am responsible for joining the class at the scheduled time, which is 9:00am, and I should plan to log in at least 5 minutes early to ensure that I am able to access the virtual classroom. The classroom closes at 9:05 and no one will be permitted to enter after that time.

E. If I am not able to attend the class, I will give 24 hours notice (by phone or email) of rescheduling or pay the $35 rescheduling fee. A no-show and logging in after the class has begun will be cause for rescheduling and the rescheduling fee.

F. Class participation is required. I will have good quality Internet, video, and audio.

G. I will be prepared, in a quiet and private space, free of all outside distractions and will utilize headphones for additional security for at least 4 hours.

H. Confidentiality is expected: Recording or photographic imaging of any part of the class session is strictly prohibited. For privacy considerations, no other person is allowed to attend the class with me. This includes parents, spouses, domestic partners, siblings, friends, etc. Virtual backgrounds are not permitted in this class.

I. I will be free of substances, including medical marijuana, and refrain from smoking of any type during class.

J. 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.

K. In a crisis or emergency situation, that needs immediate attention, whereby 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.

L. Payment is required to confirm my seat and receive the link for class. Seating is limited and classes close 10 days before the date of the class or when all the seats are full, whichever comes first.

M. Once registration and payment are received, the link for the class will be emailed to the email address provided. This takes place the week of class and no later than two day before the class date in an email called "appointment reminder" and I know to look in my junk/spam folder if I do not see it in my inbox.

N. In order to complete the entire course, and receive a certificate of completion, a follow up quiz will be required and I will complete it online within 3 days of the class. A passing score of 70% or higher is needed to receive a certificate of completion, which will be automatically emailed to me. Further, if I fail to complete the quiz, within the given timeframe, I will be required to retake the class at my expense.

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

Name of person participating in class *

First Name Last Name

Date of Birth *

Date

Email (needed to send class link and materials) *

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 and/or Court (please include first and last name) *

i.e John Smith

ADULT class: (Must be at least 20 years old). All classes are $75 unless otherwise noted.

TEEN/YOUNG ADULT class: (Must be between 14 and 19 years old): All classes are $70

Alternatives to Aggression/Ethics & Victim Empathy Empathy (Combined) - April 24 Alternatives to Aggression/Ethics & Victim Empathy (Combined) - May 29 Petty Theft - March 27 Petty Theft - May 1 Substance Use - April 11

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

First Name Last Name

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

I am paying for the class and will submit payment online, within the next 24 hours of this registration, at https://www.nichange.com/payment (copy and paste into your browser). Click on the big blue CLICK TO PAY NOW button at the top of the main page. (NOTE: If using a card that is not in your name, please put your name in the box marked "company"). Probation/Human Services/Other referral source has agreed to provide a voucher for the class. (If this option is selected please contact the department paying for the class within 24 hours of this registration to inform them of the class date so they can submit funding to confirm your seat).

Signature of person registering for class or parent ONLY *

Clear

NIC ONE-DAY CLASS PROGRAM CONSENT AND REGISTRATION FORM