Student Application–Align Health Careers Institute, LLC

Student Application
Please select the course you wish to enroll in:
Full Name

First NameMiddle InitialLast Name
Address

Street Address

Apartment/Unit #

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
Date

Method of Payment (Check One)
Approved and regulated by the Texas Workforce Commission, Career Schools and Colleges, Austin, Texas.

PHOTOGRAPHS/ VIDEO CONSENT, WAIVER, AND RELEASE
Student Name

First NameLast Name
I CONSENT AND GIVE PERMISSION TO Align Health Careers Institute, LLC to photograph and or video of self. I understand that any such photographs, and all rights associated with them, will belong solely and exclusively TO Align Health Careers Institute, LLC which shall have the absolute right to copyright, duplicate, reproduce, alter, display, distribute, and/or publish them in any manner, for any purpose, and in any form including, but not limited to, print, electronic, video, and/or Internet.

I voluntarily waive any and all rights with respect to any such photographs, including compensation, copyright, and privacy rights and any right to inspect or approve such photographs and/or copy, print or other materials that may be used in connection with them. I hereby release and discharge, and agree to hold harmless, Assured and Associates, its officers, agents and employees, and all persons acting under its permission or authority, from any TO Align Health Careers Institute, LLC claims and liability in connection with such photographs and/or their use.

I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS

CONSENT, WAIVER, AND RELEASE FORM, AND I SIGN IT FREELY AND

VOLUNTARILY.
Student Signature
Date

MonthDayYear
Date
Director Signature

For Office Use Only – Director Authorization, For Director use only. Students should leave this section blank.
Date

MonthDayYear
For Director use only. Students should leave this section blank.

Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.

If this application leads to enrollment, I understand that false or misleading information in my application or interview may result in my release.
Signature
Date

MonthDayYear
Date
Guardian Signature (If applicable)
Date (If applicable)

MonthDayYear
Date
Should be Empty:

Student Application

PHOTOGRAPHS/ VIDEO CONSENT, WAIVER, AND RELEASE

Disclaimer and Signature