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Black Belt Healers

Registration Checklist

 

Check off the following items as you complete them.

____ Application for Enrollment

____ Online Enrollment Agreement (NVSM)

____ Napa Valley School of Massage Policies

____ Student Rights

____ Rules and Regulations

____ Professional Ethics

____ Refund Table

____ Payment Agreement

____ Enrollment Agreement

____ Pinewood Karate Enrollment

____ Pinewood Karate Waiver

____ Pinewood Karate Notice to Students

 

Mail all documents to:

Daniel E. Andrews III, M.D.
Black Belt Healers
1131 Trancas Street
Napa, CA 94558

Napa Valley School of Massage

Application for Enrollment

(This is Not an Enrollment Agreement, Please Print or Type)

 

Legal Name of Applicant (Last, First, Middle):_________________________________________________________________

Social Security #: _________-_________-____________ Date of Birth (Month, Day, Year): ________/________/________

Telephone Number: Home (__________) __________-____________ Work (__________) __________-__________

Email Address: ___________________________________________________________________

Mailing Address: Street _______________________________________________________________________
(if different from above)

City _____________________________________ State _________ Zip ____________________

Gender: Female ___ Male ___
(check one)

How did you learn about the Napa Valley School of Massage? ____________________________________________________________

Please list your previous education/training: _________________________________________________________________________

__________________________________________________________________________________________________________

Emergency and Family Addresses

Parent Name and Address:

Name: _________________________________________________________________________
First , Last

Address: Street: _____________________________________________________________

City _____________________________________ State _________ Zip ____________________

Phone: Home (__________) __________-__________ Work (__________) __________-__________

 

Emergency Contact Name and Address:

Name: _________________________________________________________________________
First , Last

Address: Street: _____________________________________________________________

City _____________________________________ State _________ Zip ____________________

Phone: Home (__________) __________-__________ Work (__________) __________-__________

 

Napa Valley School of Massage

 

Enrollment Agreement for Basic 250 hour Course By Distance Learning

 

Student Name:   ___________________________________  Social Security Number:  _____-_____-_____

Course Title: “Restorative Massage Therapy”      Total hours of course work to be completed: 250 hours ONLINE –DISTANCE LEARNING FORMAT

Course Description: a comprehensive course with an emphasis on Eastern & Western massage techniques with overview of anatomy, physiology & special attention on professional ethics; incorporated with practical application on patients.

Student's Start Date:  ____/____/____         Scheduled Completion Date:  ____/____/____

Upon successful completion of the above course, you will receive a Certificate of Completion.

 

Fees:

 

 

 

Registration Fee:

$300.00

The Napa Valley School of Massage will retain the $300.00 registration fee should the student withdraw from the course and cancel the Enrollment Agreement.

Tuition: 

$2,000.00

Prorated upon course withdrawal.  Refer to the refund table.  If a student should submit the Notice of Cancellation after 50 hours, he/she would receive a tuition refund of 25% (50 hours completed/250 hours of tuition paid).

 

TOTAL CHARGES:

$2,300.00*

 

All amounts paid for instruction, supplies & required uniform. Does not include text book estimated at $20.00.

* You are responsible for this amount.

* This Contract is a legally binding instrument when signed by the student and accepted by the school. 

* BUYER'S RIGHT TO CANCEL - the student has the right to cancel the enrollment agreement and obtain a

   refund.  The student must complete the written “Cancellation Notice” form and submit it to the Associate

   Director.  The refund is prorated after the second week of access to the online course.

Tuition refunds are given to students according to the SAMPLE REFUND TABLE.  To be eligible for a refund, the student must fill out, sign and date a notice of cancellation.  The following is a summary of the refund table.  A 100% tuition refund will be given to a student any time before the fifth business day following the date of enrollment. A partial tuition refund will be given to a student on a pro rata basis according to the refund table.  No refund will be given after 60% of the class has been completed.  Please review the refund table carefully.  If you have no questions, sign the statement at the bottom that says: “I have read and understand the refund table.”  If you as an enrolling student in the Napa Valley School of Massage are not a California resident, you will not be eligible for protection or financial recovery from the student tuition recovery fund.

__________________________________________        “I have read and understand the refund table.”

Signature of Student

__________________________________________  Initial that copy was given to the student _____

Signature of Associate Director

If you have any complaints, questions or problems which you cannot work out with the school, write or call:

Bureau for Private Postsecondary and Vocational Education,

P.O. Box 980818, West Sacramento, CA 95798-0818, (916) 445-3427

 

Napa Valley School of Massage

School Policies

 

Graduation Requirements

Students are expected to complete 100% of assignments, maintain 90% attendance, 70% accuracy on written exams, 70% accuracy on oral exams and maintain the highest standards of appearance and personal hygiene as described in the Rules & Regulations.

Dismissal Policy

Students may be suspended or dismissed by the director if they are unable to fulfill the graduation requirements. Students will be counseled and placed on probation for less than 90% attendance, less than 70% GPA, failure to pay tuition or breaking the Rules & Regulations which includes disobeying the dress code, drug and alcohol policy and behavior policy.

If the student is unable to rectify the problems discussed during the counseling session, they will be placed on a one week suspension. If the problem should arise again, the student will be dismissed from the school.

 

Attendance Policy

Students are expected to maintain a 90% attendance rate. Arriving late or leaving early will be considered a tardy. Two tardies will be considered an absence. Students will be counseled after 3 absences and may be dismissed after the 6th absence.

 

Leave of Absence Policy

Students who need to take a leave of absence should complete the Leave of Absence form and submit it to the Associate Director. If the student chooses to resume class, they will have to attend the next available course from the beginning at no extra charge.

 

Cancellation Policy

Students may cancel their enrollment in the Napa Valley School of Massage. They must complete the Cancellation Notice form. Students who cancel within the ten days of access to the online course will receive a 100% refund of their paid tuition. The registration fee however is NON-REFUNDABLE after the fifth business day following first access to the online course. The Student’s tuition refund is prorated after the second week according to the Refund Table.

I understand and agree to the above policies of the Napa Valley School of Massage.

 

Student’s Signature _______________________________________________ Date ________/________/________

Napa Valley School of Massage

Notice of Student Rights

*This Notice is important. Keep it for your records

 

1. You may cancel your enrollment at the Napa Valley School of Massage at any time (please review Cancellation Notice Form). Registration Fees for courses are NON- REFUNDABLE. You may cancel your enrollment at any time in the first ten days without being charged tuition (you will forfeit the Registration Fee). Should you cancel your enrollment after the first ten days, you will be charged tuition for the course work completed based on the Refund Table. Students taking the Online Course will be charged based on a percent of the 27 lessons completed.

2. If the school closes before you graduate, you may be entitled to a refund. Contact the Bureau for Private Postsecondary and Vocational Education at the address and telephone number printed below for information.

Bureau for Private Postsecondary and Vocational Education
P.O. Box 980818, West Sacramento, CA 95798-0818
(916) 445-3427

3. If you have any complaints, questions or problems which you cannot work out with the school, write or call:

Bureau for Private Postsecondary and Vocational Education
P.O. Box 980818, West Sacramento, CA 95798-0818
(916) 445-3427

 

I have read and understand my rights as a student at the Napa Valley School of Massage.

 

Student’s Signature _______________________________________________ Date ________/________/________

 

Signature of School Representative _______________________________________________ Date ________/________/________

 

Napa Valley School of Massage


Rules & Regulations

 

1. Students are not permitted to wear jewelry.

2. Perfume or cologne is not permitted.

3. Fingernails must be kept short and clean.

4. Students must keep their uniform clean.

5. Use of alcohol or before or during class is prohibited and is reason for dismissal.

6. Use or possession of drugs or drug paraphernalia is prohibited.

7. Smoking is not permitted.

8. Eating , drinking or chewing gum is not permitted during class.

9. No talking or laughing while class is in session.

10. Profanity is not permitted.

11. Be on time for class. Leaving class early without prior arrangements is not permitted.

12. Attendance is manditory. Two tardies will be considered an absence. Three absences warrant academic counciling. A total of six absences is a reason for dismissal.

13. Online assigments are mandatory. Students will not be permitted to move on to new lessons without completing all previous online assignments.

14. Report any incident/injury to instructor immediately.

 

I have read and understand the rules and regulations for the Napa Valley School of Massage.

 

Student’s Signature _______________________________________________ Date________/________/________

Napa Valley School of Massage

 

Professional Ethics

 

 

1. Never discuss patients with others. This includes unnecessary conversation within the clinic and all conversations outside the clinic. All patient information is strictly confidential.


2. Patient information may only be released with signed release.


3. Avoid discussing your personal life with patients.

4. Sexually oriented jokes and conversations are strictly prohibited. The therapist should terminate the massage and notify the clinic Director immediately.

5. Never touch a patient's breasts or genital area. Massage of the buttocks should only be undertaken with the patient's prior permission. Massaging the buttocks through clothing or a clean towel will provide the patient with more privacy and comfort.

6. Should you ever feel uncomfortable during the treatment, you should terminate the massage and immediately report the incident to the clinic Director.

7. Never diagnose patient's illnesses or try to treat medically. In the clinic, you are working under the direct supervision of a physician.

8. Should you notice or become aware of a potential health problem, you should recommend that the patient mention this to their physician. State simply "I recommend you show this to your doctor". Do not elaborate, never offer advice or recommend medication.

9. Never criticize another therapist or health care provider.

10. Never remove or borrow clinic property.

11. Clinic patients at the Heart & Health Center have a doctor - patient relationship with Dr. Andrews. They may only receive massage treatments in the clinic under Dr. Andrews' supervision. Students and faculty are not permitted to treat these patients outside the clinic or without Dr. Andrews' order.

12. Follow up appointments and questions about billing will be handled by the clinic staff. Notify the Director about any problems.

13. Always knock before entering a patient's room.

14. Never interrupt the doctor or another therapist unless an emergency exists.

15. Always be respectful of the patient's privacy. Keep their body covered except for the area you are working on.

16. Never accept tips.

17. Be polite and say "your welcome" when a patient thanks you for your treatment.

18. Make detailed massage therapy chart notes at the conclusion of the treatment.

 

 

I have read and understand the above professional ethics.

 

                                                           

Student’s Signature

Napa Valley School of Massage

Blank Refund Table

 

Registration Fee

$300.00

The Registration Fee is NON-REFUNDABLE.

Tuition

$_____

The Tuition will be refunded at 100% within the first ten days following enrollment date. After this date, the student will be charged a percent of tuition based on the course work completed.


Tuition Refund:

Sample Calculation for Refund

 

Refund Policy

A refund will be given to a student who completes the Notice of Cancellation. This refund is based on the following:

A 100% refund will be given up to ten days following enrollment. The Registration Fee is NON-REFUNDABLE. The student’s tuition refund is pro rata after ten days following enrollment. After the student has completed 60% of the course, no refund will be issued.

 

 

Date of Enrollment                                                                                               

 

Hours Completed by Student

 

Hours of Course total

 

Percent of Course Completed

 

Tuition Paid to Date

 

% Course Completed X Tuition Paid

 

Refund to Student

 

 

 

I have read and understand the Refund Table.

 

 

Student’s Signature _______________________________________________                                                                                             Date ________/________/________

Napa Valley School of Massage

Payment Agreement

 

The policy of the Napa Valley School of Massage is for all students to pay their tuition upon enrollment.  On occasion, the NVSM will agree (on an individual basis) to allow students to make payments.  These payments must be made based on the below schedule.  Failure to make tuition payments in a timely fashion will result in termination of this agreement and interruption of the student’s studies.

 

 

 

This agreement for payment is made between ______________________________ and

                                                                                                                                                Student’s Name                                               

the Napa Valley School of Massage on ____/____/____.    

                                                              Date of Agreement

 

The student agrees to pay $300.00 for the non-refundable uniform and registration fee today to reserve his or her space in the class.

 

The student further agrees to pay the total tuition of $___________________

 in______(number of equal payments). Note: All payments must be of equal amount and in no more than four payments (including the initial payment).

 

The first payment is due on the first day of class.

 

The second payment is due on (date) __________.

 

The third payment is due on (date)    __________.

 

The last and final payment is due before the last day of class and before the final exam.

 

I have read and understand this payment agreement.  I understand that I will not be granted a Diploma from the Napa Valley School of Massage until my tuition is paid in full.  I also understand that I may be dismissed from the Napa Valley School of Massage for failure to pay tuition.

 

 

 

 

I agree to the terms of this agreement.

 

 

                               

 

Signature of Student _________________________________________  Signature of Associate Director _________________________________________

 

 

Date _________________________________________ Date_________________________________________

Pinewood Karate Inc.

Enrollment Agreement

Applicant Information

Last Name:                                                 First Name:                                             M.I.

Date of birth:

Gender:  M  F

Home Phone:                          

Cell phone:

Current address:

Email:

Fax:

City:

State:

ZIP Code:

S.S.N:

Employed By:

Emergency Contact

Name of a relative not residing with you:

Address:

Phone:

Email:

Cell Phone:

City:

State:

ZIP Code:

Relationship:

Person Responsible for Payment (if different from above)

Last Name:                                                 First Name:                                             M. I.

Current address:

Phone:

E-mail:

Fax:

City:

State:

ZIP Code:

Release for emergency medical treatment

Physician:

Medical Insurance:

Referred By

Friend:

Yellow Pages:

Print Ad:

Other:

 

Pinewood Karate Inc.

Waiver of Liability

 

 

I have been advised of the risks and benefits of practicing Pinewood Karate Inc. I am aware of the possibility of injury in this activity and therefore release liability against Pinewood Karate Inc., school members, instructors or owners in the event an injury occurs. I will only use the information and skill I receive during the course of this instruction for self defense. I agree to notify Pinewood Karate Inc. in writing should I have any significant health problem that would increase my risk of injury. I also agree to provide Pinewood Karate Inc. with a physician's release prior to beginning practice should I have a significant health problem. Lastly, I recognize that it is my responsibility to purchase annual insurance chosen by Pinewood Karate Inc. I am also aware that in the event I violate any of the regulations, Pinewood Karate Inc. may terminate my membership.

 

 

 

 

Applicant's Signature:_________________________________Date:_______________

 

 

Parent's Signature (if under 18 years old):_____________________________________

 

Date:_____________

 

 

Telephone Number:___________________________________

 

Notice to Student

 

  • Student shall fill in all blanks and read all three pages of this agreement before signing.
  • Student certifies that he/she is in good health. If the student has a known health problem, he/she must provide the school of this ailment and get a written release form their physician. The founder of Pinewood Karate Inc., who is a physician, does not assume a patient/physician relationship with any student of Pinewood Karate Inc.
  • Students in Pinewood should take promotion tests upon the recommendation of their instructor.
  • Seminars, testings, and special events are separate fees not included in the terms of this agreement.
  • CONSUMERS RIGHT OF CANCELLATION: You may cancel this agreement penalty free within 3 days of execution date of agreement, exclusive holidays and weekends upon mailing or delivering written certified notice of cancellation to Pinewood Karate Inc. You may cancel this agreement if Pinewood Karate Inc. goes out of business and fails to provide facilities within 10 miles of, or moves its facilities more than 10 miles from the present facilities.
  • AUTOMATIC RENEWAL: This agreement will be automatically renewed at the rate originally established in this enrollment agreement unless a “Request for Inactive Status” form is completed and received by the billing office. This form may be picked up in the office at the school.
  • Students agree to make installment payments to Pinewood Karate Inc. if so noted on page 1.
  • This agreement comprises the entire agreement pertaining to membership and no other agreement shall be recognized by us.

 

 

Membership Agreement

 

This agreement executed the date shown on the front by and between Pinewood Karate Inc. hereinafter referred to as the School, and the student, who has caused his/her signature to be affixed hereto, hereinafter referred to as Student.

 

The School agrees to provide martial art instruction during the scheduled instruction hours of the School. Student understands that it is his/her responsibility to attend instruction sessions. Student understands that the entire course fee is due and payable according to the terms and conditions of this agreement whether or not the student chooses to attend instructional sessions provided by the School. In consideration for the School's promises to provide instruction facilities, Student agrees and promises to pay the course fees shown as on front.

 

In the event of default in the payment of any installment or fee in accordance with the terms above, or a breech of any of the covenants herein contained to be performed by the Student, the balance due under this agreement shall become immediately due and payable.

 

Student agrees to abide by the rules and regulations governing the conduct and operation of instruction sessions, students, and observers, in order to promote efficiency, safety and recognition of the instruction certification, as prescribed by the School. Student acknowledges that the rules and regulations governing the school have been adopted, and may be changed from time to time, and Student agrees to abide by all such rules and regulations as adopted or hereafter amended. The hours of operation may be changed at the discretion of the school.

 

The School reserves the right to revoke or terminate any membership.

 

Student agrees that all exercises and/or courses are undertaken at members own risk. The Student understands that procedures and exercises involved in instruction and participation as explained to him/her by an assistant of the School. The Student understands that there is risk of personal injury involved in the course of instruction and with this knowledge agrees to indemnify and save harmless the School from all losses caused by accident or injury to the Student or to third persons, whom may be a Student of the School, in the event that either the Student or said third person is injured in any way during the performance and execution of exercises.

 

The company owning the School and the agents and employees shall not be responsible for damaged, lost or stolen articles, inside or outside the facility.

 

The School reserves the right to amend or add to these rules and conditions to adopt new rules and conditions as it may deem necessary.

 

I, the Student or the Member, irrevocably authorize the School, its successors and assigns, and those acting under its authority, to copy, use, publish, for art, advertising, trade, or any other lawful purpose whatsoever, photographic portraits, pictures, digital or video tapes of me, in which I may be included in whole or in part.

 

Inconsideration for the training obtained, I agree that I will not, during the continuance of this agreement, and for a period of five (5) years following termination of my association with Pinewood Karate Inc., engage in teaching Martial Science or offering similar training or instruction within a twenty (20) mile radius of any school operated by Pinewood Karate Inc. without the express written authorization of the same.

 

 

Student Signature:______________________________________Date:______________