Forms | The Capstone Institute

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*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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

Name

This field is for validation purposes and should be left unchanged.

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Student Information

CANCELLATION REFUND POLICY

STUDENT ACKNOWLEDGMENTS:

CONTRACT ACCEPTANCE

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