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Hands2Hearts Academy Enrollment Form
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Email *
Today’s Date *
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Full Legal Name *
Date of Birth *
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Full Street Address and ZIP CODE (ex: 3934 Dixie Highway Louisville, Ky 40216) *
Social Security number( ex: 555-55-5555) *
Phone Number (ex:(555)555-5555) *
Scrub Size *
Required
Cohort Choice *
What Cohort Date Would You Like To Start (Please refer to website for schedule)  Hands2Hearts Academy *
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Are you a "The Spot" student that is receiving Tuition Assistance"? *
Are you a Kentuckiana Works Career Center Voucher Student (WIOA) (see Facts. Below) *
What is the full name or your Career Coach or Case Worker (if you have one)
Are you a “Power to Work” participant with a DCBS Voucher? *
Are you a Goodwill Excel Center Student that reports to Ashley Hickerson that is receiving Tuition Assistance? *
The Louisville Urban League will offer up to 50% Tuition Assistant if you:
 1. Work at least 20 hours a week, 
2. Meet with a LUL career coach 
3. Complete required documentation
4. Pay the program enrollment fee. 
 Are you interested?
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County of Residence? *
What is your annual income? *
Payment choice *
Will you need Childcare Services? Please be sure to review the policy for childcare in the Student Handbook on page5 ( PLEASE NOTE: childcare services are not available for DCBS voucher students, you must use your support services) *
How old is the child? 
Per the Student handbook children must be 5 years or older 
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Will you need Transportation to Clinical?  ( PLEASE NOTE: transportation services are not available for DCBS voucher students, you must use your support services) *
Emergency Contact (Name, Number relationship) *
Are you taking any medications you would like to make the Academy aware of? *
Medication Name
Do you have any preexisting medical conditions you would like the Academy to be aware of? *
List Conditions
Do you Acknowledge Receipt and Understanding of the Student handbook *
Do you Acknowledge Understanding of the Refund Policy? Please see page 8 of the Student Handbook

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Do you acknowledge you received information to the Students Rights and Responsibilities with Respect to the Student Protection Fund? (Pages 16-17 of the Student HandBook) *
Please review State Criminal Background Guidelines for Program eligibility https://nurseaide.kctcs.edu/nurse-aide-resources/media/pdfs/KRS%20216.789.pdf *

PHOTO USE RELEASE FORM 



I do hereby grant and authorize Hands2Hearts PLLC and Hands2Hearts Academy LLC the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or video taken of me by Hands2Hearts PLLC and Hands2Hearts Academy LLC to be used in and/or for legally promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats and markets now known or hereafter devised. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing.

I understand and agree that these materials shall become the property of Hands2Hearts PLLC and Hands2Hearts Academy LLC and will not be returned.

I hereby hold harmless, and release Hands2Hearts PLLC and Hands2Hearts Academy LLC from all liability, petitions, and causes of action which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate?
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Disclaimer Of Employment Guarantee:
While the Academy offers job placement assistance and referral. The Academy cannot in any way guarantee employment after the student has successfully completed the program of study. Likewise the Academy does not guarantee that a student would pass the necessary state examination for being recognized as a  State Registered Nurse Aide.
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Right To Cancel/Suspend/Terminate and Make Changes:
The academy may cancel suspend or terminate the enrollment agreement at any time if the undersigned student violates any of the following policies and or agreements 
-failure to maintain satisfactory academic progress
 -failure to comply with the academy's attendance policy -failure to comply with the academy student conduct policies 
-failure to meet all financial obligations to the Academy Violation of any of the conditions as set forth and agreed to in the enrollment agreement. The Academy also reserved the right to change or modify the program contents instruction curriculum clinical time equipment staff or materials as deemed necessary. Such changes may be necessary to keep pay with technology advances, to cooperate with clinical training venues, to replace instructors who are not available and to improve the teaching methods or procedures. In no event will such changes diminish their competency or content of the program or result in any additional charge to the student.
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Student Acknowledgement
This agreement is a legally binding instrument when signed by the student and accepted by Hands2Hearts Academy. Your signature on this agreement acknowledges that you have been given reasonable time to read and understand it and that you have been (a)given a written statement of the refund policy and how it applies, (b) a course catalog including the description of the course, all material facts concerning the Academy  and the program course instruction which are likely to affect your decision to enroll. Prior to signing this enrollment agreement you must be given a catalog which you are encouraged to review prior to signing this agreement. This document contains important policies. Immediately upon signing this agreement you will be given a copy of it to retain for your records.  I understand that this is a legally binding contract my signature below certifies that I have read understood and agreed to my rights and responsibilities and that the academy's cancellation and refund policy have been clearly explained to me. By signing, I also certified that I have received an explanation of the Academy's graduation requirements, physical demands work conditions and safety attendance behavior and confidentiality requirements (verbal), placement disclosure visited/ toured the Academy. I would hold harmless Hands2Hearts Academy and any of the affiliated clinical facilities of Hands2Hearts Academy of any liability.
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Square Invoice of a non refundable $52.00 enrollment fee (square fees included) will be emailed at the same time of this enrollment form.  Your enrollment will not be processed until the invoice is paid.  Do you understand? *
A copy of your responses will be emailed to the address you provided.
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