Proprietary School Enrollment Agreement Sample 12-2009 - DOC

							                   GENESEE HEALTH CAREERS, LLC                    ENROLLMENT AGREEMENT
                          G-3308 MILLER RD., FLINT, MI 48507; PHONE: 810-407-8126
                  EMAIL: LMCFADDENGHC@COMCAST.NET WEB: GENESEEHEALTHCAREERS.ORG
          Genesee Health Careers, LLC admits students and makes available to them its advantages, privileges and
          courses of study without regard to race, color, sex, religion, national origin, sexual orientation or disability.
Date: ____________________                                     Student ID #: ____________________
Student name: ________________________________________________________________
Address:_____________________________________________________________________
City: ___________________________________ MI                           Zipcode: ____________
Cell Phone: _____________________________ Home Phone: __________________________
Social Security #: ________________________ Date of Birth: ________________________
Email address: ____________________________________________@___________________
Driver’s License #: ___________________________________ State issued by: ____________
Educational Background:      Circle Highest Level of Education Completed:
                   HS Diploma GED Associate Degree Bachelor Degree
Name of High School Attended__________________________________________
                   City________________________________         State______
Year Graduated____________ if obtained GED, Year Obtained:___________
Name Used While Attending: _____________________________________________
Previous Education: (Copy required for student file)
High School – Diploma               G.E.D.         Other: ____________________________________
Any allergies: Y N if yes, what? ________________________________________________


        Date Your Program Begins: ___/___/___                   Date Your Program Ends: ___/___/___

Program Name and tuition charges/fees:
[ ] Nurse Aide: Tuition $1,215.00; application fee $25.00; criminal background check/drug testing fee
$75.00; and $75.00 for study guide/books for a total of $1,390.00 for 90 clock hours.
[ ] Health Care Technician (pre-requisite Nurse Aide from GHC): Tuition $1,512.00; and $335.00 for
study guide/additional books for a total of $1,847.00 for 112 clock hours. Background /drug testing and
application fees apply to those who have not taken Genesee Health Careers’ Nurse Aide program for a total cost
of $1,947.00.
[ ] Medical Assistant I: Tuition: $5,675; application fee $25.00; criminal background check/drug testing fee
$75.00; and $195.00 for study guides/books for a total of $5,965.00 for 420 clock hours.
[ ] Medical Assistant II: Tuition $3,685.00; $300 for study guides/books for for a total of $3,985.00 for a total
of 273 hours. Medical Assistant I and Medical Assistant II combination is $9,950.00
[ ] Pharmacy Technician: Tuition $2,835.00; application fee $25.00; criminal background check/drug testing
fee $75.00; and $300.00 for study guides/books for a total of $3,235.00 for 210 clock hours
[ ] CPR/BLS: Tuition $89 (includes book).
******************************************************************************************
Entrance Requirements: Must be 17 years of age or older, high school or GED certificate completed prior to
class enrollment.
Clock/Credit hours: classes are based on clock hours.
School uniform: Student will be provided one uniform set for our programs.
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Tuition & Fees                        Agency Authorization:                           FOR OFFICE USE ONLY
$ ________ Program Tuition            Agency:__________________________
$ __75.00 _ Background                Auth. Code: ______________________              Origin of Registration
                                                                                      Phone-in
$ __25.00__ Reg. fee                                                                  Walk-in
$ _________ Textbooks                 Agency Rep: ______________________              Mail-in
$ _________ Program Total                                                             Faxed-in
$ _________ Int. payment              Phone #: __________________________
$ _________ Balance due
                                      TOTAL TUITION & FEES                            Rcvd. By _______________
                                                                                      Date __________________
Refund Policy :
   1. All tuition and fees paid by the student/applicant shall be refunded if requested within three (3) business
      days after signing a contract with the school. All refunds shall be returned to the student within 30
      days.
   2. You will receive a full refund, without interest, if rejected by the school before enrollment, or if a
      program is cancelled by the school. All refunds shall be returned to the student within 30 days. Once
      the three days ellipse the following applies.
   3. If you cancel prior to the start of the scheduled class, your paid tuition and other fees will be refunded.
      The application fee of $25 will be retained by the school. All refunds shall be returned to the student
      within 30 days.
   4. Once class has begun, if you withdraw or did not attend/no show to class on the first day, there will be
      no refund. There are no refunds for textbooks, uniforms, criminal background fees and application fees
      as we have reserved a seat for you for this program.

STUDENT TO INITIAL:
____     Nurse Aide students will receive their catalog on the first day of class from the instructor.
____     Medical Assistant and Health Care Technician students will be provided a hard copy of the school’s
         catalog and policies prior to the first day of class.
____     Student understands state and national certification fees are not included in their tuition and at their
         expense.
___      I understand this contract will not be in force and effect until signed by both myself and a school
         representative.
___      I understand the refund policy as stated above.
___      I understand that coursework and/or credit from this school may not be transferable to other institutions
         of education and acceptance is at the discretion of the receiving institution.

*****************************************************************************************
Student, or guardian, has received a completed and signed copy of this agreement.

Student’s Signature: _________________________________________Date:________________
Print Student’s Name: _______________________________________
If the student is under the age of 17, Parent/Guardian must sign:
_______________________________________________                        Date:__________________
Print Parent/Guardian’s Name: ___________________________________________
School Official’s Signature: _____________________________________Date:_____________
Print School Official’s Name:_______________________________________________
COPIES RECEIVED FOR ADMISSION:
[ ] DRIVER’S LICENSE     [ ] SOCIAL SECURITY CARD                          [ ] FERPA
[ ] MICHIGAN I.D.        [ ] HIGH SCHOOL DIPLOMA                           [ ] G.E.D.STUDENT PROVIDED:
[ ] VIDEO RELEASE FORM   [ ] UNIFORM ISSUED
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Last modified on 9/20/2011