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School Enrollment Agreement


School Enrollment Agreement document sample

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									2008 ENROLLMENT AGREEMENT                                                                                               School of Shiatsu and Massage
                                                                                                                        PO Box 889 Middletown, CA 95461

___________________               _____________________                 ___________________ _________________                                ___________          _______
 Legal First Name                  Last Name                             Nickname/Alias     Driver’s License Number                          State issued         Expires

_____________________________                     ________________________                  _____ _____________                _________          __________________
Address                                           City                                      State Zip Code                     Country            Country of Citizenship
______________________________________                           _________________________________                       _________________________________
 Phone                                                           Business Phone                                          E-Mail Address

The student may cancel this enrollment agreement and receive a refund by providing a written notice to Director, School of Shiatsu and Massage, PO Box 889,
Middletown, CA 95461. The student has a right to full refund of all charges less the amount of $75, the registration fee for the upcoming class, if the notice of cancellation
is made prior to or on the first day of instruction. In addition, the student may withdraw from a class after instruction has started and receive a pro rata refund of the unused
portion of the tuition and other refundable charges, if the student has completed 60% or less of the instruction. If the student has paid deposits on more than one class, each
time he or she notifies the school of the intention to cancel the registration on one or more classes, the student will be refunded all deposits except the $75 registration fee.
If students give notice 14 days before a class begins, they may transfer their deposit to a subsequent class of their chose. If the school cancels or discontinues a class, the
school will make full refund of all charges. Refund will be paid within 30 days of cancellation or withdrawal.

My signature below certifies that I have read, understood, and agreed to my rights and responsibilities, and that the institution’s cancellation and refund policies
have been clearly explained to me.

____________________________________________________________________________                                        _______________________________
 Signature of Student                                                                                                Date

The school is required by State law to keep records of our students’ employment. This information is confidential and its sole use is for evaluating the
effectiveness of our classes. To help us, please check the appropriate statement and sign below. The primary reason I am taking this class is:
     To improve my skill in bodywork or a related field in which I am already employed.
      To begin a program to which additional studies will be added before I seek employment, at which time I will notify the School.
      Looking for employment in bodywork..

____________________________________________________________________________                                        _______________________________
 Signature of Student                                                                                                Date

LICENSE AND CERTIFICATION Please use additional paper and attach to form:

Have you ever been licensed or certified in the healing and/or helping profession                            _____Yes      ______ No
If yes, by what Organization?

___________________________________ ___________________________________ ______________________                                                 _______________________
Organization Name                   Address                             City, State, Zip                                                       Phone #

         If yes, please use additional paper and attach to form to explain.
     1. What is your current state of health? (check one box)      Great Good Satisfactory          Poor
     2. Are you physically challenged in any way?                                                                                   _____Yes _____ No
     3. Do have any learning disabilities?                                                                                          _____Yes _____ No
     4. Have you any past or recent injuries due to accident, or sports?                                                            _____Yes _____ No
     5. Have you ever cancelled enrollment in or been terminated from, an educational or training program?                          _____Yes _____ No

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       The following information is for Instructor and Office use only and shall be kept within your student files.

    Current Employment: ________________________________________________________________________________________

     Educational Background: _____________________________________________________________________________________
      1. What are your personal and/or professional goals for taking classes?

       2. What is your previous related training? Please include institution names, dates, locations and copies of transcripts if desired.

      3. Describe the qualities that you possess that enable you to be successful with your course of study in the field?

       4. Please describe your strengths and challenges.

   In case of emergency notify:

         Name                                                                   Relationship


         Day Phone                                                             Evening Phone


This agreement is a legally binding document when signed by the student and accepted by the school of Shiatsu & Massage which is not a public
institution. Your signature on this agreement acknowledges that you have been given a reasonable time to read and understand the Enrollment
Agreement and that you have been given: (a) a written statement of the refund policy including examples of how it applies and; (b) a catalogue or have
accessed the web site at and have viewed class descriptions that includes information for all material facts concerning the school
and its programs which may be likely to affect your decision to enroll. You will be given a copy to retain for your records. This agreement is for the
2008 academic school year.

       I the undersigned, hereby acknowledge that I have been advised of the content and course outline of the School of Shiatsu &
   Massage intensives. I have been advised that each intensive involves hands-on application of massage in its various forms and will
   also involve physical activity and movement. I freely enter into School of Shiatsu & Massage intensives and related activities at my
   own risk. I expressly and voluntarily waive and release WORLDWIDE AQUATIC BODY WORK ASSOCIATION, d/b/a THE
   SCHOOL OF SHIATSU & MASSAGE, its agents, employees and assigns, from any and all liability for any claims, demands,
   and/or actions of any kind, including, but not limited to, personal injury and/or property damage that may occur as a result of or in
   the course of any School of Shiatsu & Massage intensive, and/or arising out of the use of the lodging premises.

         I agree to defend, indemnify and hold harmless WORLDWIDE AQUATIC BODYWORK ASSOCIATION, d/b/a
     SCHOOL OF SHIATSU AND MASSAGE, its agents, employees and assigns, from any and all claims, actions or demands by
     any other party or individual which may arise out of or result from my participation in any School of Shiatsu & Massage intensive.
         I acknowledge that I have read and understand the contents of this waiver and release and have received a copy thereof.

          Dated: _________________                  Signature:   _______________________________________________

                                                    Print Name: _______________________________________________

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         1.         To maintain high standards of personal and academic integrity at all times.
         2.         To treat all members of the School community with respect, goodwill and concern for their well being.
         3.         To show respect and care for the personal belongings, property of others and that of the School and Harbin Hot
          4.        To follow ALL rules of Harbin Hot Springs posted and/or verbally advised by Harbin staff.
          5.        To honor and follow reasonable directives of a school official as applicable and requested.
          6.        To behave in a manner that will not be harmful or disruptive to the learning environment, to the school's reputation or
                    the reputation of the bodywork profession.
          7.        If you come into the course with a partner, to be sensitive and exercise discretion concerning the expression of your
          8.        Violations of ethical boundaries will not be tolerated, and may be cause for immediate dismissal from the class and/or
          9.        We request that you disclose to the School Director, Joyce Reim any information about inappropriate actions by
                    instructors, assistants or interns.
          10.       It is our intention to create an environment that totally supports the learning experience. In all personal interchanges
                    the students are requested to be respectful of other student's physical and emotional space. Students who are deemed
                    to be acting inappropriately (this being decided by a consensus of instructors and assistants) will be either warned or
                    dismissed from the class (this being decided by a consensus of instructor and school administrator) depending upon
                    the nature of the indiscretion. In the case of a dismissal, tuition will be refunded according to the Refund Policy stated
                    in the School catalogue.
          11.       To avoid any interest, activity or influence that might be in conflict with the instructor's obligation to act in the best
                    interests of the student or the profession.
          12.       To respect other students' boundaries with regard to privacy, disclosure, exposure, emotional expression, beliefs and
                    their reasonable expectations of professional behavior.
          13.       There might be times when you do not wish to give or receive bodywork from a particular fellow student. This may be
                    due to personal, interpersonal or other reasons and/or boundaries, whether known or inexplicable. You have the right
                    of refusal, and may exercise this if needed. Please note that excessive refusal may prompt immediate instructor or staff
                    intervention and academic counseling.
          14.       To acknowledge and respect the limitations and contradictions for massage and bodywork when you are working with
                    your classmates and treat them as if they are clients.
          15.       To remember that it is your and your fellow students' right to request and/or to provide additional draping according to
                    the other students' level of comfort and/or need for privacy.
          16.       To follow all policies, procedures, guidelines, and codes, requirements and School regulations that are advocated by
                    the School of Shiatsu and Massage. The School reserves the right to amend these policies at any time as deemed

          I understand that my signature below states that I have read the "Students Code of Ethics" and understand each policy and agree
          to comply.

          Dated: _________________                  Signature:   _______________________________________________

                                                    Print Name: _______________________________________________

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