ENROLLMENT APPLICATION/AGREEMENT

Transcription

1 2021 JUSTIN RD., SUITE 197 FLOWER MOUND, TX Texas School License Number: MS1009 ENROLLMENT APPLICATION/AGREEMENT Thank you for applying with our school. Please print; answer the following questions as completely and accurately as possible. PERSONAL INFORMATION: TODAY S DATE: / / FIRST NAME: MIDDLE INITIAL: LAST NAME: ADDRESS: CITY: STATE: ZIP: HOME PHONE: WORK PHONE: MOBILE: DATE OF BIRTH: SOCIAL SECURITY NUMBER: ADDRESS: EMERGENCY CONTACT NAME: PHONE NUMBER: RELATIONSHIP: Students are responsible for keeping the above contact information current with the schools records. Should a student not update their school records and a transcript is issued with inaccurate information a fee of $25 will be assessed for records update and reissuance of transcripts. COURSE ENROLLMENT INFORMATION: ENROLLMENT FOR: 500-hour Professional Massage Therapy Diploma Program - $5, (450 Class hours, 50 hour Internship) (Student Initial) 570-hour Professional Massage Mastery Diploma Program (optional) - $5, (450 Class hours, 120 hour Internship) ($4, after completion of Mastery Program) (Student Initial) Individual Hours/Classes $ (Student Initial) Fast Track Day Class Night Class Individual Hours Monday Thursday Monday Thursday Monday Thursday 10am-2pm/6pm-10pm 10am-2pm 6pm-10pm Program Start Date Program Start Date Program Start Date Program Start Date (Student Initial) (Student Initial) (Student Initial) (Student Initial) STUDENT S ESTIMATED GRADUATION DATE: / / Student Initials Administration Initials PAGE 1of 6 - APPLICATION/ENROLLMENT AGREEMENT

2 TODAY S DATE: Chosen Class at Time of Enrollment: Day Night Fast Track Individual Hours Class Order 1st 2nd 3rd 4th 5th 6th 7th Name of Class Start Date End Date Day or Night It is IBS policy, should a student wish to switch any class/classes for another date than what is listed above, the student must submit a Change of Class Schedule form and receive a Director s approval a minimum of 5 days prior to the requested class is to begin. Change of Class Schedule forms are available from the front desk. There is a $25 schedule change fee due at time of request. Failure to pay schedule change fee or to submit a Change of Class Schedule form in the approved time frame will result in the student having to take the classes above in the order listed. Student Initials Administration Initials MEDICAL HISTORY PLEASE CHECK YES OR NO TO THE FOLLOWING QUESTIONS: QUESTION YES NO Do you have any known chemical, aroma or skin allergies? Are you pregnant? Do you have an emotional or psychological disorder? Do you have an addiction to any illegal substances or alcohol? Have you been diagnosed or are currently being treated for any type of cancer? Do you have any skin disorders or problems? Do you have any breathing disorders? Do you have any blood disorders? Do you have arthritis, joint disorders, or spinal disorders? Do you have any type of heart condition? Are you currently taking prescribed medications? Do you wear contact lens? Do you suffer from headaches? Have you had any surgeries or injuries in the past 5 years? Do you have any type of contagious disease or disorders?

3 PAGE 2 of 6 - APPLICATION/ENROLLMENT AGREEMENT TODAY S DATE: If you have answered yes to any of the above questions, or if you have any health concerns that could potentially keep you from being able to complete our program or perform all related activities please list below. I,, ATTEST I AM IN GOOD HEALTH & THAT I HAVE DISCUSSED ANY AND ALL HEALTH ISSUES WITH MY HEALTH CARE PROVIDER(S) ALONG WITH THE ADMINISTRATION OF IBS PRIOR TO ENROLLMENT. I FULLY UNDERSTAND THAT MASSAGE THERAPY IS CONSIDERED A HEALTH CARE SERVICE & THAT CERTAIN MEDICAL CONDITIONS MAY BE INTENSIFIED, ACTIVATED, AND/OR EXACERBATED BY RECEIVING MASSAGE AND/OR HYDROTHERAPY. I REALIZE THAT I WILL BE RECEIVING AND PROVIDING MASSAGES AND HYDROTHERAPY SERVICES AS A PART OF MY TRAINING. I RELEASE AND HOLD HARMLESS, INSTITUTE OF BODYWORK STUDIES, THE ADMINISTRATORS OF, EMPLOYEES, CONTRACT LABORERS, OWNERS AND HEIRS FROM ANY LIABILITY. Applicant Name Date UPON SIGNING THIS DOCUMENT, THE APPLICANT EXPRESSES HIS/HER INTENTION TO ENROLL IN OUR PROGRAM AND ACKNOWLEDGES THE MOST CURRENT VERSION OF THE SCHOOL CATALOG AND COMPLETE COURSE & ENROLLMENT INFORMATION IS AVAILABLE IN WRITTEN FORM UPON REQUEST AND ON LINE AND IS CURRENTLY VOLUME #. Program Outline Admission requirements Schedule of tuition, fees, and other charges Cancellation and refund policy Length of time for completion of our programs, including internship hours Class schedule including estimated break and meal times Attendance and progress policies, including requirements and fees for make-up hours Policies regarding grievance policies Pupil-teacher ratio Student conduct policy Number of hours which must be successfully completed before a student can be licensed as a massage therapist in the State List of instructors, their qualifications, and the subject area taught by each Information indicating how a prospective student may obtain copies of the Massage Therapy Act, Texas Occupations Code, Chapter 455 State and IBS policy regarding student s who are ineligible for licensure I AGREE TO COMPLY AND FULLY UNDERSTAND EACH OF THE 13 BULLET ITEMS ABOVE AS OUTLINED IN THE SCHOOL CATALOGUE. I HAVE BEEN GIVEN REASONABLE TIME TO REVIEW ALL THE MATERIAL IN THE SCHOOL CATALOG/ENROLLMENT AGREEMENT & HAVE BEEN GIVEN THE OPPORTUNITY TO TOUR THE INSTRUCTIONAL FACILITY AND INSPECT EQUIPMENT PRIOR TO SIGNING THIS ENROLLMENT AGREEMENT. I MAY DECLINE THE TOUR SHOULD I CHOOSE. I HAVE FURNISHED INFORMATION DISCLOSING MY PREVIOUS EDUCATION, TRAINING, AND WORK EXPERIENCES. I UNDERSTAND THIS WILL BE EVALUATED BY STATE AND MAY RESULT IN THE PROGRAM LENGTH BEING SHORTENED AND THE COST REDUCED BASED ON APPROVAL AND PROPER STATE DOCUMENTATION. A LETTER FROM THE STATE WILL BE ATTACHED TO THIS DOCUMENT IF APPLICABLE. I FURTHER REALIZE THAT COMPLAINTS MAY BE MADE TO THE MASSAGE THERAPY EDUCATIONAL PROGRAM AND THE DEPARTMENT OF STATE HEALTH SERVICES, MASSAGE THERAPY LICENSING PROGRAM, P.O. BOX , AUSTIN, TEXAS , (512) I HAVE BEEN OFFERED THE OPPORTUNITY TO READ THE MASSAGE THERAPY ACT AND THE RULES OF THE DEPARTMENT INCLUDED IN 25 TEXAS ADMINISTRATIVE CODE, CHAPTER 140 AND MADE AWARE A COPY CAN BE OBTAINED ON THE SCHOOLS AND DEPARTMENTS WEBSITE. PAGE 3 of 6 - APPLICATION/ENROLLMENT AGREEMENT Admin Initials

4 I HAVE BEEN MADE AWARE THAT THE STATE OF TEXAS REQUIRES ONLY THE MINIMUM 500 HOUR COURSE OF INSTRUCTION FOR LICENSURE AS A MASSAGE THERAPIST, AND ANYTHING BEYOND THAT IS STRICTLY VOLUNTARY. I HAVE READ, AND FULLY UNDERSTAND THE GRADING AND ATTENDANCE POLICIES. I UNDERSTAND THAT IF I FAIL A CLASS DUE TO MISSING MORE THAN 15% OF THE SCHEDULED HOURS, OR FROM FAILURE, THAT CLASS WILL HAVE TO BE REPEATED AND PAID IN FULL (AS OUTLINED IN THE SCHOOL CATALOG) BEFORE RECEIVING MY TRANSCRIPT. FINAL CLASS GRADES FOR EACH CLASS AND FINAL GRADES ON TRANSCRIPTS WILL REFLECT EITHER A P FOR PASS OR AN F FOR FAIL. I HAVE READ AND UNDERSTAND THE RULES AND REGULATIONS OF THE INTERNSHIP PORTION OF THE PROGRAM. I AM AWARE THAT WHILE IN MY INTERNSHIP I WILL BE EXPECTED TO PERFORM MASSAGE/SPA SERVICES ON EITHER GENDER OF CLIENTS. I UNDERSTAND THAT I WILL BE REQUIRED TO GIVE AND RECEIVE MASSAGES AND AGREE TO CLASS PARTICIPATION AND IN STUDENT CLINIC IN ORDER TO GRADUATE. I AM ALSO AWARE THAT I WILL BE EXPECTED TO MASSAGE AND RECEIVE MASSAGES FROM EITHER GENDER WHILE IN CLASS. I UNDERSTAND THAT VIDEO AND STILL PHOTOGRAPHY MAY BE USED DURING CLASS FOR PROMOTIONAL & INSTRUCTIONAL MATERIALS. PLEASE INDICATE IF YOU ALLOW IBS TO UES YOUR IMAGE BELOW: I ALLOW IBS TO USE MY IMAGE FOR PROMOTIONAL AND INSTRUCTIONAL MATERIAL I DO NOT ALLOW IBS TO USE MY IMAGE FOR PROMOTIONAL AND INSTRUCTIONAL MATERIAL I UNDERSTAND THAT THE FINAL GRADE GIVEN FOR EACH CLASS WILL REFLECT A PASS OR FAIL STATUS. I UNDERSTAND THAT TUITION PAYMENTS ARE DUE BY THE 15 TH OF EACH MONTH, REGARDLESS OF WHAT DAY THE 15 TH FALLS ON. SHOULD A PAYMENT NOT BE MADE OR MADE IN FULL ON OR BY THE 15 TH. A LATE FEE OF $30 WILL BE ASSESSED TO YOUR TUITION ACCOUNT. I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE & UNDERSTAND THAT, IF OMITTED; FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. THIS (6) PAGE FORM MUST ACCOMPANY (A) COPY OF MY CURRENT DRIVER S LICENSE (B) COPY OF MY SOCIAL SECURITY CARD (C) $100 NON-REFUNDABLE APPLICATION FEE (D) STATE FORM EXPLAINING THE 570-HOUR IS OPTIONAL (ONLY IF ENROLLING IN MASTERY PROGRAM). I AM AWARE THAT TRANSCRIPTS WILL NOT BE ISSUED WITHOUT PROVIDING IBS WITH THE ABOVE FORMS OF IDENTIFICATION. APPLICANT NAME / / TODAY S DATE APPLICANT SIGNATURE IBS ADMINISTRATIVE SIGNATURE PAGE 4of 5 - APPLICATION/ENROLLMENT AGREEMENT

5 TUITION AGREEMENT INSTALLMENT PAYMENT PLAN Student Information Student Information School Information Name: Institute of Bodywork Studies Address: 2021 Justin Rd., #197 City, State, Zip: Flower Mound, TX Phone Social Security: MS#1009 DOB: In exchange for the purchase of education related services I am entering into this financial contract for tuition, fees, supplies, and services which will be rendered to me as per outlined in the school catalogue and this financial agreement. I have been given access to the schools catalogue and fully understand and agree to comply with terms. Additionally, I understand that no finance charges are being assessed on the amounts I owe, but that I may incur late fees and other charges as described in this Enrollment Agreement. Application and supply fee are not part of the tuition amount and are to be considered additional fees. Should I be enrolled in the 570-hour program and change to the 500-hour program I am aware I will be charged a program change fee of $150 and will be responsible for the full cost of the program tuition and will loose any tuition scholarship. Changing programs should be done prior to completing hour 50 of Internship. Should my tuition and or fee be paid by a 3 rd party and said party does not remit payment within 90 days of my program start date I will become responsible for paying the total amount due from 3 rd party. A new tuition payment plan with new amounts due must be drawn up and signed by both parties. Outlined below are additional student and responsible party information. Additional possible fees may include but are not limited to: 1. Late Charges: If a full account payment is not made by the 15 th of the month you will be charged $30, unless prior arrangements have been made. 2. Payment Return Fee: If a payment is returned or refused by my bank for any reason, I agree to pay a charge of up to $50 for each payment so returned to the extended permitted by law. 3. Right to Prepay: I have the right to prepay all or my part of my obligation under this Tuition Portion of the Enrollment Agreement at any time without penalty. 4. Default: If I fail to pay any installment under this Enrollment Agreement when due, then subject to applicable law and after you provide to me any notice that may be required by law, you may declare the entire unpaid balance and all other fees due under this Enrollment Agreement to be immediately due and payable. Additionally, if I fail to pay any installment when due, I understand and acknowledge that you may stop providing any or all of the services that I was receiving under this Enrollment Agreement. Additionally, I understand that I will not receive transcripts until all of my tuition and fees have been paid in full. Applicable late fees will apply until account is paid in full. 5. Collection Costs: Unless prohibited by applicable law, I agree to pay you all amounts, including reasonable attorneys fee, and collection agency, court and other collection costs that you incur in enforcing the terms of this Contract. The Collection Costs that I agree to pay also include fees and costs incurred in connection with any appellate proceedings. 6. Charges for Optional Services: If I request and you agree to provide optional services to me in connection with this Enrollment Agreement you may charge me and I agree to pay the fees for such services. The fee will be disclosed to me before I accept any such service. 7. Communicating With Me: To the extent permitted by law, and without limiting any other rights you may have, I expressly consent and authorize you to communicate with me in connection with this Enrollment Agreement using any phone number, physical or address that I have provided to you, or that I provided to you in the future. You may communicate with me using any current or telephone/text service or otherwise directed to me. I authorize the use of such means of communication even if I and or responsible party will incur costs to receive such phone messages, text messages or s. 8. Applicability of Provisions: If any of the provisions contained in the Tuition Installment portion of this Enrollment Agreement are in conflict with any applicable laws or statutes, the appropriate laws or statues will apply. All other provisions of this Enrollment Agreement will remain in effect. 9. Additional Transcript Copies: A $25 fee will be assessed to any additional transcript request after graduation of program. 10. Make-Up Attendance Hour Fee: A fee of $25 per clock hour for make-up hours requested outside normal program hours or office hours. 11. Monthly Payment Modification Request: Should I have a certain hardship that keeps me from paying the on going monthly payment amount agreed to in this contract and I request a new payment plan, an addendum to this contract will be drawn up and a $25 fee will be assessed; attached to the original contract stating, but not limited to the following information: new monthly payment amount, the dates in which the new monthly installment amounts are in effect, and signed by both the student and school Administration. 12. Student Requested Withdraw or Re-enter Program: A $100 fee will be assessed to my tuition account should I choose to withdraw/re-enter the program. 13. Leave of Absence Fee: A $50 fee will be assessed to my tuition account should I take a leave of absence from the program. 14. Changes to Internship Schedule Fee: Should I choose to change or not be able to follow the internship schedule that was agreed upon, signed and dated by both myself and a member of IBS Administrative Staff before the start of internship, a new schedule will be designed to better fit my schedule. The new said schedule will be dated and signed by both and IBS staff member and myself; additionally, I will be assessed a $20 fee for each schedule change. 15. Missed Internship Appointments: I understand that should I not be on premises for any reason, to perform scheduled service(s) the full amount of the missed service will be charged to my tuition account. Additionally, should I be late for any scheduled service causing the scheduled appointment to not start on time I will be charged the full amount of said service; fees will be assessed to my tuition account. 16. Repeat of a Failed Course: The following repeat courses are individually priced and are the same dollar amount for either program: Health & Hygiene $200, Hydrotherapy $200, Business & Ethics $450, Anatomy $500, Physiology $250, Pathology $450, Kinesiology $500, MT1 $1,250, MT2 $750 in addition to a $50 administration fee. 17. Repeat of a Failed Internship: The following repeat courses are individually priced: 500 hour class $500, 570 hour class $570 APPLICANT SIGNATURE DATE Administration Initials PAGE 5 of 6 - APPLICATION/ENROLLMENT AGREEMENT

6 INSTITUTE OF BODYWORK STUDIES INSTALLMENT AGREEMENT (NO INTEREST) PROGRAM COSTS Item Cost Date Paid Application Fee: Supply Fee: Tuition Base: Total Less Discounts or Scholarship: - Balance Down Payment: - Amount to be Financed: Student Initial I agree to pay the remaining balance of $ in monthly payments of $. My first payment will be due on the 15 th of and there after on the 15 th of each month until balance is paid in full. I understand that full tuition payments are due on or before the 15th of the month. I understand that late fees will be assessed should payments be late. Student Initial Admin Initial I understand that full tuition payments are due on or before the 15th of the month. I understand that a late fees will be assessed should payments be late. I understand that tuition payments may be made in cash, personal check, debit, Mastercard, or Visa. Should I become more than 2 payments behind, I may be withdrawn from the program until my account is made current, including the late fees. I understand that IBS accepts local & out of state checks, but not two-party or post dated checks. All checks are to be made payable to IBS or Institute of Bodywork Studies. I understand if my tuition check is returned, for whatever reason, the maximum NSF charge allowed by law will be assessed. I understand that once a check has been returned, IBS will no longer accept personal checks from me and that all future payments must be made in cash, money order, cashier check, Visa or Mastercard. I understand that unpaid amounts may be reported to credit agencies after 60 days. I agree to pay all collection agency fees should I fail to pay the total sum due, within 10 days after receiving a letter from Institute of Bodywork Studies requesting payment. I understand the school may enforce violation of this agreement with a lawsuit. I understand, by signing this contract, I agree that venue lies in Denton County, TX; which means the enforcement suit can be brought in Denton County. By signing this contract, I also agree that should the school be suing for breach of contract and prevails, I must pay the attorney fees and costs of the lawsuit. If my account is sent to collections, I understand all fees will be assumed. I understand, should I decide to change from the program in which I originally enrolled, that I will be responsible for the additional amounts owed associated with the price difference (if any) of the programs. I understand that a new installment tuition contract for the remaining amount of tuition due (including change of program fees) at the time of the program change will be signed by both myself and IBS. Once the conditions of this enrollment agreement have been met in accordance with the rules and regulations set forth per Title 25, Texas Administrative Code, Chapter 140, Health Professions Regulation Subchapter H Massage Therapists Regulation , I will be provided with a transcript. I may then apply for licensure with the Texas Department of Health. STUDENT SIGNATURE DATE / / PAGE 6 of 6 - APPLICATION/ENROLLMENT AGREEMENT