Pennsylvania Registration Form

Pennsylvania Registration Form
Student Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Present Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone (home)*
Please enter a valid phone number.Format: (000) 000-0000.
Telephone (cell)*
Please enter a valid phone number.Format: (000) 000-0000.
Truth In Lending Payment Plan Conditions

Authority. This part, known as Regulation Z, is issued by the Bureau of Consumer Financial Protection to implement the Federal Truth in Lending Act, which is contained in title I of the Consumer Credit Protection Act, as amended (15 U.S.C. 1601 et seq.). This part also implements title XII, section 1204 of the Competitive Equality Banking Act of 1987 (Pub. L. 100-86, 101 Stat. 552). Furthermore, this part implements certain provisions of the Real Estate Settlement Procedures Act of 1974, as amended (12 U.S.C. 2601 et seq.). In addition, this part implements certain provisions of the Financial Institutions Reform, Recovery, and Enforcement Act, as amended (12 U.S.C. 3331 et seq.)
Student Signature*

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Student Signature*

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Student Signature*

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Student Signature*

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Auto draft Payment Schedule

1st autopay the Monday before class 1 | 2nd the Monday before class | 3 3rd the Monday before class 5 | 4th the Monday before class 7 | Last Payment the Monday before class 9 *We accept all major credit cards, checks and automatic withdrawal*
CANCELLATION AND REFUND POLICY:

(a)Refund and withdrawal policy-resident programs of 6 weeks or longer duration. (1) For a student canceling after the fifth calendar day following the date of enrollment as defined in § 73.132 (relating to application or registration fee) but prior to the beginning of classes, monies paid to the school shall be refunded except the nonrefundable amount of the application or registration fee as calculated in § 73.132. (2) If a student enrolls and withdraws or discontinues after the term, semester or quarter has begun but prior to completion of the term, semester or quarter, the following minimum refunds apply: (i) For a student withdrawing from or discontinuing the program during the first 7 calendar days of the term, semester or quarter, the tuition charges refunded by the school shall be at least 75% of the tuition for the term, semester or quarter, including all radiology fees and textbook fees. (ii) For a student withdrawing from or discontinuing the program after the first 7 calendar days, but within the first 25% of the term, semester or quarter, the tuition charges refunded by the school shall be at least 55% of the tuition for the term, semester or quarterand shall not include any radiology fees and textbook fees. (iii) For a student withdrawing or discontinuing after 25% but within 50% of the term, semester or quarter, the tuition charges refunded by the school shall be at least 30% of the tuition and shall not include any radiology fees and textbook fees. (iv) For a student withdrawing from or discontinuing the program after 50% of the term, semester or quarter, the student is entitled to no refund. (v) For refund computations, a term, semester or quarter may not exceed 18 weeks. Refunds will be issued within 30 days of the date of student notification, or date of school determination (withdrawn due to absences or other criteria as specified in the school catalog). 22 Pa. Code § 73.134
§ 73.133. Refund in the event of rejection

An applicant rejected by the school is entitled to a refund of monies paid
§ 73.135. Termination date

The termination date for refund computation purposes is the last date of recorded attendance of the resident student or the date the nonresident student requests cancellation
Student Signature*

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I hereby acknowledge receipt of the School’s catalog dated___ ________________, which contains information describing programs offered, and equipment/supplies provided. The School’s _______________________ catalog is included as a part of this enrollment agreement, and I acknowledge that I have received a copy of this catalog.______ Student initials*

MonthDayYear
Date
Also, I have carefully read and received an exact copy of this enrollment agreement. ____Student Initials*

MonthDayYear
Date
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 also understand that this institution does not guarantee job placement to graduates upon program/course completion or upon graduation. _____ Student Initials*

MonthDayYear
Date
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 Dental Assistant Academy. My signature below signifies that I have read and understand all aspects of this agreement and do recognize my legal responsibilities in regard to this contract.*

MonthDayYear
Date
The Schools Catalog
Student Signature*

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Student Signature*

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Student Signature*

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Applicant Signature*

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Date*

MonthDayYear
Date
Parent or Guardian Signature (if applicable)

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Date

MonthDayYear
Date
School Representative

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Date

MonthDayYear
Date
Consent for Photo Release

We at Union Centre Institute value your privacy and are committed to protecting your personal information. This consent form outlines how we may use your image, likeness, and other personal information for marketing purposes. Please read it carefully and indicate your consent or refusal by signing and dating below.
Consent for Image and Likeness Usage:
I, _ First Name Last Name _______ grant Union Centre Institute the permission to use my image, likeness, and voice in photographs, videos, audio recordings, and any other media format for marketing and promotional purposes. This includes, but is not limited to, use in printed materials, websites, social media platforms, advertisements, presentations, and press releases
I agree to provide testimonials and quotes about my experiences at Union Centre Institute for use in marketing materials. I understand that these testimonials and quotes may be used in various formats including, but not limited to, print materials, websites, social media, and advertisements
I consent to the publication of my academic achievements (e.g., awards, honors, scholarships) for marketing and promotional purposes by Union Centre Institute. This may include publication in newsletters, websites, social media platforms, and press releases
I agree to participate in marketing events organized by Union Centre Institute, such as open houses, recruitment fairs, and promotional campaigns. This may involve speaking engagements, panel discussions, or other activities aimed at promoting the school.
I agree to provide testimonials and quotes about my experiences at Union Centre Institute for use in marketing materials. I understand that these testimonials and quotes may be used in various formats including, but not limited to, print materials, websites, social media, and advertisements
If the student is under the age of 18, the parent or legal guardian must provide consent for the usage outlined in this form.
By signing below, I indicate that I have read and understood the terms of this consent form and hereby give my consent for Union Centre Institute to use my image, likeness, and personal information for marketing purposes as described above.
Signature*

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This is a fill in the blanks field. Please add appropriate blank fields and text.
By signing below, I indicate that I have read and understood the terms of this consent form and hereby give my consent for Union Centre Institute to use my image, likeness, and personal information for marketing purposes as described above.
Should be Empty:

Pennsylvania Registration Form

Truth In Lending Payment Plan Conditions

Auto draft Payment Schedule

CANCELLATION AND REFUND POLICY:

§ 73.133. Refund in the event of rejection

§ 73.135. Termination date

Consent for Photo Release