32105 First Avenue South Suite B2, Federal Way, WA 98003

Phone: 253-874-0516 Fax: 253-874-0693

Website: crystalpointcna.com E-Mail: info@crystalpointcna.com

STUDENT DATA COLLECTION FORM

The Workforce Board (the state agency that regulates this school) requires that we ask you for this
information, by law (RCW 28C.10.050). Providing your social security number is voluntary. The
information you provide, including your social security number, is used for research purposes only and to
plan for Washington’s workforce training needs. By law, the information you provide on this form
cannot be given out by any state agency as public information. The Workforce Board will not disclose
data to anyone except authorized Workforce Board employees or contractors working on specific
research activities, who follow strict confidentiality procedures. This format follows the information
required to be submitted by the school as part of the annual student data report.

Last Name

MI

Address

City

State

Zip

Phone

Date Of Birth
Social Security No

Race







Are you Hispanic in origin? *


Sex


Are you disabled? *


Are you a military veteran? *


Highest grade completed








Name and address of last school attended

Date For School

Enrollment Agreement

32105 First Avenue South, Suite B?, Federal Way, WA 98003
Phone: (253) 874-0516/ Fax: (253) 874-0693
Website: www.crystalpointena.com E-Mail: crystalpointhealth@alberthacurtsi

This Enrollment Agreement is between the above-named school and
Student Name

Telephone

Physical Address

City

State

Zip

Course or program title
The school agrees to provide the following training

CNA

Start date
Completion date

Program duration is 3 weeks and includes: 35 hours Theory, 13 hours Skills Labs, 40 hours Clinical, = 88 total hours

COST:

Registration fee…………………………….…………………………….…………………………….…………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………….….. $ 50.00

Tuition …………………………….…………………………….…………………………….…………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………………………………….. $ 650.00

Books.…………………………….…………………………….…………………………….…………………………….…………………………………………………….…………………………………………………….…………………………………………………….………………………………………………. $ 650.00

Books.…………………………….…………………………….…………………………….…………………………….…………………………………………………….…………………………………………………….…………………………………………………….………………………………………………. $ 50.00

Gait belt.…………………………….…………………………….…………………………….…………………………….…………………………………………………….…………………………………………………….…………………………………………………….……………………………………………. $ 15.00

Supplies and Materials.…………………………….…………………………….…………………………….…………………………….…………………………………………………….…………………………………………………….…………………………………………………….……………………… $ 40.00

CPR/First Aid (If needed).…………………………….…………………………….…………………………….…………………………….…………………………………………………….…………………………………………………….…………………………………………………….…………………… $ 100.00

TOTAL COST FOR THE COURSE.…………………………….…………………………….…………………………….…………………………….…………………………………………………….…………………………………………………….…………………………………………………….………… $ 905.00

METHOD OF PAYMENT
I agree that the payment of program costs will be satisfied by




List third party payer (if applicable):

Down Payment…………………………….…………………………….…………………………….…………………………….…………………………………………………….…………………………………………………….…………………………………………………….……………………………………….….. 50.00%

Monthly payments…………………………….…………………………….…………………………….…………………………….…………………………………………………….…………………………………………………….…………………………………………………….………………………………………..$ 000.00

Late Fee for payments received after due date.…………………………….…………………………….…………………………….…………………………….…………………………………………………….…………………………………………………….…………………………………………………. $ 50.00

Other required items for the class are:

  • Watch with a secondhand

NOTICE OF FINANCIAL OBLIGATION

Washington law requires the following information to be supplied to each student enrolling in a private vocational school licensed under Chapter 28C.10 RCW. One copy of this notice bearing original signatures must be attached by the school as addenda to that individual’s enrollment agreement, as well as a copy must be provided to the enrollee by the school.

ACKNOWLEDGMENT BY ENROLLEE

1. I understand and accept that any contract for training I enter into with the above-named school contains legally binding obligations and responsibilities.

2. I understand and accept that repayment obligations will be placed upon me by any loans or other financing arrangements I enter into as a means to pay for my training.

3. I understand that any enrollment contract I enter into will not be binding or take effect for at least five days. excluding Sundays and holidays, following the last date such a contract is signed by the school and me, provided that I have not entered classes.

Name

Dated This
Day Of

HOW TO FILE A COMPLAINT:

Washington law requires private vocational schools to inform students how to file a complaint. By signing this form, you acknowledge this process has been explained to you. Below are the next steps the school must take in discussing this policy with you, along with information about the complaint process.

DISCUSSION ABOUT COMPLAINT POLICY REQUIRED:

First, a school representative must discuss the school’s complaint policy with you. Following this discussion, you will be provided with this attachment to sign. After you sign this form, the school will give you a copy for your personal records. The school will also keep a copy on file.

ACKNOWLEDGMENT OF COMPLAINT PROCESS BY STUDENT

1. The school has described the grievance and/or complaint policy to me.

2. I understand that the policy can also be found in the school catalog.

3. I know I should first try to resolve a complaint or concern with my instructor or school administrator.

4. I understand nothing prevents me from contacting the Workforce Board at 360-709-4600 at any time with a concern or complaint, and complaint forms are: http://wtb.wa.gov/PCS Complaints.asp.

5. I understand that I have one year to file a complaint from my last date of attendance.

6. I further understand that in the event of a school closure, I have 60 days to file a complaint.

7. I also understand that complaints are public records. 8. Finally, I acknowledge that details about the complaint process, my rights, and any restrictions on the time I have to file a complaint can be found at http://wtb.wa.gov/PCS Complaints.asp

REGISTRATION FORM

First Name

Middle Name

Last Name

Address

City

State

Zip

Telephone number

Date of Birth
SS#

EMAIL

Personal Data Questions:
Have you ever been convicted of any crime? *


ave you ever had any license, certificate, registration or other privilege to practice a health care
profession denied, revoked, suspended or restricted by a state, federal or foreign authority?


If yes please explain

When do you want to start your class

I understand that there will be a $50.00 fee for any late payments made after agreed upon due date

Applicant Signature

Today Date
Name

Relationship to you:

Phone

Secondary Phone

HOW DID YOU HEAR ABOUT US:
Referral (who referred you)

From Channel



AGREEMENT NOTICE:
This agreement will be binding only when it has been fully completed, signed, and dated by the student and an authorized
representative of the school prior to the time instruction begins.

CHANGES TO AGREEMENT NOTICE:

Any changes in the agreement will not be binding on either the student or the school unless such changes are

acknowledged in writing by an authorized representative of the school and by the student (or the student’s parent or

guardian if he/she is a minor).

CANCELLATION AND REFUND POLICY:

  1. The school must refund all monies paid if the applicant is not accepted. This includes instances where a starting

     class is canceled by the school.

  2. The school must refund all monies paid if the applicant cancels within five business days (excluding Sundays and

     holidays) after the day the contract is signed or an initial payment is made, as long as the applicant has not begun

     training.

  3. The school may retain an established registration fee equal to ten percent of the total tuition cost, or one hundred

     dollars, whichever is less, if the applicant cancels past the fifth business day after signing the contract or making

     an initial payment. A “registration fee” is any fee charged by a school to process student applications and

     establish a student record system.

  4. If training is terminated after the student enters classes, the school may retain the registration fee established

     under (3) of this subsection, plus a percentage of the total tuition as described in the following table:

If the student completes this amount of training:                                           The school may keep this
                                                                                                                         percentage of the tuition cost:
One week or up to 10%, whichever is less                                                                                             10%
More than one week (or 10%), whichever is less,                                                                                25%
but less than 25%
25% through 50%                                                                                                                                       50%
More than 50%                                                                                                                                        100%

    5. When calculating refunds, the official date of a student’s termination is the last day of recorded attendance:

        (a) When the school receives notice of the student’s intention to discontinue the training program; or,

        (b) When the student is terminated for a violation of a published school policy which provides for termination; or,

        (c) When a student, without notice, attends less than 45 hours out of the required 48 hours of class.

    6. All refunds must be paid within thirty calendar days of the student’s official termination date, and will be paid by

       check.

DISCONTINUED PROGRAMS:

If the school discontinues instruction in any program after students enter training, including circumstances where

the school changes its location, students must be notified in writing of such events and are entitled to a pro-rata

refund of all tuition and fees paid unless comparable training is arranged for by the school and agreed upon, in

writing, by the student. A written request for such a refund must be made within 90 days from the date the

program was discontinued or relocated, and the refund must be paid within 30 days after receipt of such a request.

TERMINATION BY THE SCHOOL:

A student who fails to maintain satisfactory progress, violates safety regulations, interferes with other students’ work, is

disruptive, obscene, under the influence of alcohol or drugs, or does not make timely tuition payments, is subject to

immediate termination.

CANCELLATION OF CLASSES:

The school reserves the right to cancel a starting class if the number of students enrolling is insufficient. Such a cancellation will be considered a rejection by the school and will entitle the student to a full refund of all monies paid.

NOTICE TO THE BUYER:

Do not sign this agreement before you read it or if it contains any blank spaces. This is a legal instrument. All pages of this contract are binding. Read both sides of all pages before signing. You are entitled to an exact copy of the agreement, school catalog, and any other papers you may sign, and are required to sign a statement acknowledging receipt of those.

CANCELLATION OF CONTRACT:

If you have not started training, you may cancel this contract by submitting written notice of such cancellation to the school at its address shown on the contract. The notice must be postmarked no later than midnight of the fifth business day (excluding Sundays and holidays) following your signing this contract; the written notice may also be personally or otherwise delivered to the school within that time. In event of dispute over timely notice, the burden to prove service rests on the applicant.

UNFAIR BUSINESS PRACTICES:

It is an unfair business practice for the school to sell, discount, or otherwise transfer this contract or promissory note without the signed written consent of the student (or his/her financial sponsors if he/she is a minor), and a written statement notifying all parties that the cancellation and refund policy continues to apply. CERTIFICATION: I certify that I have read and understand the cancellation and refund policy and the complaint procedure; I have received a copy of the school catalog; and I am entitled to an exact copy of this Enrollment Agreement, school catalog, and any other papers I sign. I hereby agree to abide by the conditions set forth herein.

This school is licensed under Chapter 28C.10 RCW. Inquiries or complaints regarding this private vocational school may be made to:

Workforce Training and Education Coordinating Board

128 – 10h Avenue SW

Olympia, Washington 98504

Phone: 360-709-4600 Email: pvsa@wtb.wa.gov Web: wtb.wa.gov