crystalpointhealth@gmail.com | 206-819-0361
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
The Workforce Board (the state agency that regulates this school) requires that we ask you for thisinformation, by law (RCW 28C.10.050). Providing your social security number is voluntary. Theinformation you provide, including your social security number, is used for research purposes only and toplan for Washington’s workforce training needs. By law, the information you provide on this formcannot be given out by any state agency as public information. The Workforce Board will not disclosedata to anyone except authorized Workforce Board employees or contractors working on specificresearch activities, who follow strict confidentiality procedures. This format follows the informationrequired 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 White/Caucasian Black/African American American Indian or Alaska Native Hawaiian Native or other Pacific Islander Asian Multiracial Other Are you Hispanic in origin? * Yes No Sex Male Female Are you disabled? * Yes No Are you a military veteran? * Yes No Highest grade completed Less than high school graduation High school graduate GED Some post high school Certificate Associate Degree Bechelor’s Degree Master’s Degree or Higher Name and address of last school attended Date For School Next
32105 First Avenue South, Suite B?, Federal Way, WA 98003Phone: (253) 874-0516/ Fax: (253) 874-0693Website: 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
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 Cash Check Credit Card Third Party 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:
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
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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? * Yes No ave you ever had any license, certificate, registration or other privilege to practice a health careprofession denied, revoked, suspended or restricted by a state, federal or foreign authority? Yes No 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 Facebook Newspaper Craigslist Other
AGREEMENT NOTICE:This agreement will be binding only when it has been fully completed, signed, and dated by the student and an authorizedrepresentative 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:
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
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