One-Day Class Registration

ONE-DAY CLASS REGISTRATION & CONSENT FORM
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THIS FORM IS FOR THE CLASSES LISTED BELOW. FOR ALL OTHER SERVICES **DO NOT COMPLETE THIS FORM** EMAIL change@nichange.com.
Name of person taking the class*

First NameLast Name
Gender*
Birthday*

MonthDayYear
Date
Email Address (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 NameLast Name
AURORA court clients ONLY: Case number (ex: J123456)
Classes are for ADULTS who are at least 18 years old.
Please note that all classes must have at least 5 participants to be held. If we need to cancel your class, we will let you know and discuss options.
Please select the class/classes that you plan to attend, all classes are virtual:*

Alternatives to Aggression ($75): Saturday, January 18- 1:30-5:30pmTriple R ($75): Saturday, January 18- 9am-1pmPetty Theft ($75): Saturday, January 18- 9am-1pm
PAYMENT: (Select only one)*

I am paying for the class. Payment is due now to register and can be submitted at www.nichange.com/payment.Probation is sending a voucher. Email your probation officer now so they can send a voucher.
IMPORTANT!! By providing your signature, you are saying that you have read and agree to 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, call the National Suicide Hotline at 988, dial 911 or go to the emergency room.

A. Classes are held via the online platform called ZOOM.

B. 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.

C. Class starts at 9:00am or 1:30pm and runs up to 4 hours. I need to stay for the whole class in rder to receive credit for completion.

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

E. I will have good quality Internet, video, and sound at all times. A poor connecting or not being able to log in does not excuse me from the class.

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

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

H. 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.

I. Virtual backgrounds are not allowed.

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

K. 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.

L. CLASS IS NOT REFUNDABLE. 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 that class. If I have a voucher, I will owe for the cost of the class in order to reschedule.

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 and email change@nichange.com for assistance.

All questions or concerns about the class must be emailed to change@nichange.com by Friday at 12pm. The administative office is closed Friday afternoon - Sunday.
Client signature *

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ONE-DAY CLASS REGISTRATION & CONSENT FORM

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