One Day Class Consent and Registration

I understand that, by providing my information and signature below, 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.

• I understand the following limitations of ZOOM video sessions: Any internet based communication is not 100% guaranteed to be secure/confidential. I agree that National Institute for Change should not be held responsible if any outside party gains access to ZOOM personal or confidential information by bypassing their security measures.

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

• I understand that I am responsible for joining the class on ZOOM at the scheduled time, which is 9:00am, and I understand that I should plan to log in at least 5 minutes early to ensure that I am able to access the virtual classroom.

• I understand that if I am not able to attend the class that I am registered for, I will give 24 hours notice of rescheduling or pay the $35 rescheduling fee.

• I understand that a no-show for the scheduled class is a forfeiture of the class fee and I will have to pay the full fee to reschedule or a $35 fee if vouchered.

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

• I will be prepared, alone, in a quiet and private space, free of distractions and will utilize headphones for additional security for at least 4 hours. For privacy considerations, no other person is allowed to attend the class with me. This includes parents, spouses, domestic partners, siblings, friends, etc.

• Confidentiality is expected: no outside distractions, no cell phones, and no other open programs on my computer. Recording or photographic imaging of any part of the class session is strictly prohibited.

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

• I understand that one-day classes are not psychotherapy or mental health treatment; and no representation of treatment are 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, 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.

• In understand that payment is require to secure my seat for class and that class seatig is limited and that classes close 10 days before the class date or when all of the seats have been paid for.

• I undetsand that once registration and payment are received, the link for the class will be emailed to the email address provided no later than two day before the class date in an email and I know to look in my junk/spam folder if I do not see it in my inbox.

• Technical problems could occur. If the class is disrupted, the therapist will attempt to reconnect within ten minutes. If reconnection cannot occur, the session will be rescheduled by another approved method.

• I understand that in order to complete the entire course, and receive a certificate of completion, a follow up exam will be required and I will complete it within 3 days of the class. Once I have passed the exam at a 70% or higher, a certificate of completion will be automatically emailed to me.

• I further understand that, if I fail to complete the exam, within the give timeframe, I will be required to retake the class at my expense.

Name of person participating in class *

First Name Last Name

Date of Birth *

Date

Email (will be used 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.

Probation Officer and/or Court (please include first and last name)

i.e John Smith or Aurora Municipal Court

I am registering for the following ADULT class(es): (Must be at least 20 years old). All classes are $75 unless otherwise noted.

I am registering for the following TEEN/YOUNG ADULT class(es): (Must be between 13 and 20 years old): All classes are $70

Aggression and Empathy - August 23 Aggression and Empathy - September 27 Petty Theft - September 13 Petty Theft - October 18 Substance Use - August 30 Substance Use - October 11

Who will be paying for this class:

I am self-pay and will submit payment online, within the next 24 hours, at www.nichange.com for this class (A seat is only confirmed with payment). Probation/Human Services/Other referral source- If this option is selected please contact the department paying for the class within 24 hours of registration informing them of the class date so they can submit funding. Your seat is not reserved until confirmation has been received from the party funding this class.

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

First Name Last Name

Signature of participant or parent/guardian if under 15 years old *

Clear

NIC ONE DAY CLASS PROGRAM CONSENT AND REGISTRATION FORM