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THIS AGREEMENT, TOGETHER WITH THE SCHOOL CATALOG, CONSTITUTES A BINDING CONTRACT BETWEEN THE STUDENT AND CAPSTONE INSTITUTE UPON ACCEPTANCE BY THE CAPSTONE INSTITUTE. READ APPLICATION THOROUGHLY BEFORE ANSWERING QUESTIONS
Student Information
Name
*
First
Last
Date of Birth
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Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Home Phone
*
Cell Phone
Work Phone
Email
*
LAST 4 DIGITS OF SOCIAL SECURITY #
Emergency Contact Name
First
Last
Relationship
Phone
Have you ever been arrested and/or charged with any crime?
*
Yes
No
(For Pharmacy Technician Program Only) “If yes, we may require a background check before enrolling due to the possibility of the Board of Pharmacy rejecting your application on the bases of your criminal history.
Program Requirements (please confirm you meet the requirements by checking the boxes below)
Yes, I hereby certify that I have completed High School or have a GED.
Yes, I understand that the Program is offered online only and that communications relating to the Program will typically be made via email, text or telephone (including autodialing) and I confirm that I have the telephone and high speed internet access necessary to participate in and complete the Program and receive such Program communications.
Yes, I agree to comply with the Program Rules in the College Student Catalog
Your name as it appears on diploma or GED:
Date Achieved
Name and Address of High School (If Apllicable)
CANCELLATION REFUND POLICY
Rejection: An applicant rejected by the school is entitled to a refund of all monies paid. Three-Day Cancellation: An applicant who provides written notice of cancellation within three (3) business day, excluding weekends and holidays, of executing the enrollment agreement is entitled to a refund of all monies paid, excluding the $100 non-refundable registration fee. Other Cancellations: An application requesting cancellation more than three (3) days after executing the enrollment agreement and making an initial payment, but prior to logging into their student portal is entitled to a refund of all monies paid. Withdrawal Procedure: A.) A student choosing to withdraw from the school after the commencement of classes must to provide a written notice to the Director of the school. The notice must include the expected last date of attendance and be signed and dated by the student. B.) If special circumstances arise, a student may request, in writing, a leave of absence, which should include the date the student anticipates the leave beginning and ending. The withdrawal date will be the date the student is scheduled to return to from the leave of absence but fails to do so. C.) All refund requests must be submitted within 30 days of the determination of the withdrawal date. When the school is eligible (in 3 years) to participate in the federal financial aid programs, the school’s refund policy must also comply with the federal guidelines and will be described in the enrollment agreement. Tuition refunds will be determined as follows: Tuition Refund Less than 25% of program = 75% of program cost refund 25% up to but less than 50% of program = 50% of program cost refund 50% up to but less than 75% of program = 25% of program cost refund 75% or more of program = No Refund NOTICE TO BUYER: 1. Do not sign this agreement before you have read it or if it contains any blank spaces. 2. This agreement is a legally binding instrument. Both sides of the contract is binding only when the agreement is accepted, signed, and dated by the authorized official of the school or the admissions officer at the school’s principal place of business. Read both sides before signing. 3. You are entitled to an exact copy of this agreement and any disclosure pages you sign. 4. This agreement and the school catalog constitute the entire agreement between the student and the school. 5. Although the school may provide placement assistance, the school does not guarantee job placement to graduates upon program completion or upon graduation. 6. The school reserves the right to reschedule the program start date with the number if students scheduled is too small. (non-pharmacy technician programs) 7. The school reserves the right to terminate a students’ training for unsatisfactory progress, nonpayment of tuition or failure to abide established standards of conduct. 8. The school does not guarantee the transferability of credits to a college, university or institution. Any decision on the comparability, appropriateness and applicability of credit and whether they should be accepted is the decision of the receiving institution.
STUDENT ACKNOWLEDGMENTS:
I hereby acknowledge receipt of the school’s catalog dated
which contains information describing programs offered, and equipment/supplies provides. The school catalog is included as part of this enrollment agreement and I acknowledge that I have received a copy of this catalog.
*
I have carefully read and received an exact copy of this enrollment agreement.
*
I understand that the school may terminate my enrollment if I fail to comply with online progress which includes completion within 1 year of logging into to course, academic, and financial requirements or if I fail to abide by established standards of conduct, as outlined in the school catalog. While enrolled in the school, I understand that I must maintain satisfactory academic progress as described in the school catalog and that my financial obligation to the school must be paid in full before a certificate may be awarded.
*
I understand that the school does not guarantee job placement to graduates upon program completion or upon graduation.
*
I understand that complaints, which cannot be resolved by direct negotiation with the school in accordance to its written grievance policy, may be filed with the Commission for Independent Education Florida Department of Education 325 W. Gaines Street Tallahassee, Florida 32399. All student complaints must be submitted in writing to The Capstone Institute corporate office at 3416 Moncrief Rd Suite 103, Jacksonville, Florida 32209 or emailed to admin@thecapstoneinstitute.org
*
SELECT YOUR PAYMENT PLAN: The Program payment plan is 4 months from the date of enrollment.
FULL PAY PLAN: I choose to pay the Full Pay Program Price with this Enrollment Agreement.
MONTHLY AUTO PAY PLAN: I choose to pay a first payment then monthly with the credit card or bank account indicated below.
You have two payment plan options. Please check the Payment Plan you are selecting.
CONTRACT ACCEPTANCE
I, the undersigned, have read and understand this agreement and acknowledge receipt of a copy. It is further understood and agreed that this agreement supersedes all prior or contemporaneous verbal or written agreements and may not be modified without the written agreement of the student and the School Official. I also understand that if I default upon this agreement I will be responsible for payment of any collection fees or attorney fees incurred by The Capstone Institute. My signature below signifies that I have read and understand all aspects of this agreement and do recognized my legal responsibilities in regard to this contract.
Your Full Legal Name
*
Date
MM
DD
YYYY
Email
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