DIVERSE TRAINING CENTER

STUDENT ENROLLMENT AGREEMENT
PLEASE READ APPLICATION THOROUGHLY AND ASK ANY QUESTIONS YOU MAY HAVE BEFORE SIGNING
THIS ENROLLMENT AGREEMENT CONTRACT.
This agreement together with the school catalog constitutes a binding contract between the
student and the school upon acceptance by the school.
STUDENT INFORMATION:
Name: (Please print):
Social Security Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone (Home):
Format: (000) 000-0000.
Cell:
Format: (000) 000-0000.
Work:
Do you hold a high school diploma or GED?
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender:
Email:
example@example.com
Name of Parent/Guardian (if student is under 18):
PROGRAM INFORMATION
Program Title:
Program Length (Total Clock Hours):
Total Clock Hours Transferred:
Total Program Clock Hours Remaining:
Clock Hours per Week:
Class Schedule:
Start Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Anticipated Graduation Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

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Tuition: $ 575
Registration Fee: S 100
Books & Materials: $ 50
Other Costs: S 175
Total Program Cost $ 900
METHOD OF PAYMENT
FOR 5 OR MORE SCHEDULED PAYMENTS, YOUR TOTAL PAYMENT SCHEDULE WILL BE:

FOR 5 OR MORE SCHEDULED PAYMENTS, YOUR TOTAL PAYMENT SCHEDULE WILL BE:

ANNUAL PERCENTAGE RATE	FINANCE CHARGE	AMOUNT FINANCED The dollar amount the credit provided to you on your behalf.	TOTAL OF PAYMENT The amount you will have paid after you have made all payments as scheduled	TOTAL SALES PRICE The total cost of your purchase on credit including your down payment of
0%	$0	$575	$900	$900

YOUR PAYMENT SCHEDULE WILL BE

Rows	NUMBER OF PAYMENTS	AMOUNT OF EACH PAYMENT	WHEN PAYMENTS ARE DUE
$325

Student will be charged a $25 late fee when weekly payment is not received as scheduled.
NON-REFUNDABLE FEES: Books and Supplies - after student has received such materials.
All prices for programs are printed herein. All prices for programs are printed herein. There are no carrying charges associated with these programs. There are no Interest charges connected to or charged with any of these programs. Contracts are not sold to a third party at any time. Upon successful completion of the program, the school will assist each graduate with job placement; however, the school does not guarantee employment. A diploma will be issued to each student who successfully completes the program and satisfies all graduation requirements.
CANCELLATION AND REFUND POLICY
Should student be terminated or cancel for any reason, all refunds will be made according to the following refund schedule:
1. Cancellation must be made in person or by certified mail.
2. All monies will be refunded if the school does not accept the applicant or if the student cancels within three (3) business days after signing the Student Enrollment Agreement and making initial payment.
3. Cancellation after the 3rd business day, but before the first class, will result in a refund of all monies paid, with the exception of the registration fee of $100.
4. Cancellation after attendance has begun, through 40% completion of the program, will result in a pro rata refund computed on the number of hours completed to the total program hours.
5. Cancellation after completing more than 40% of the program hours will result in no refund.
6. Termination Date: The Termination date for refund computation purposes is the last date of actual attendance by the student unless earlier written notice is received.
7. Refunds will be made within 30 days of termination or receipt of Cancellation Notice.
8. Cancellation of classes by the institution after attendance has begun will result in 100 percent refund.
9. Should the prospective student not meet the entrance requirements it will result in 100 percent refund.
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time. Upon successful completion of the program, the school will assist each graduate with job placement; however, the school does not guarantee employment. A diploma will be issued to each student who successfully completes the program and satisfies all graduation requirements.
ADDITIONAL TRAINING COST:
Students are advised to attend classes and participate as directed by their instructors in order to assure completion of their program within the scheduled duration hours (see program duration specified in catalog and enrollment agreement). Students still in school beyond the total number of hours scheduled for their program of study as per their enrollment agreement will be required to pay a tuition charge for every extra hour attended. The cost of each additional hour of instruction is calculated as the cost of tuition divided by the number of hours of enrollment, based on the fees disclosed in the student's enrollment agreement contract. Students that do not successfully complete their program before reaching 150% of total hours will be automatically withdrawn as per the Satisfactory Academic Policy included in this school catalog.
Initials:
DELINQUENT STUDENT ACCOUNT BALANCE
A delinquent student account balance may be reported to a credit bureau, referred to a collections agency or litigated. The student is responsible for attorney's fees, collection agency fees, court costs, service charges, and/or interest as allowed by the law.
Initials:
ACKNOWLEDGEMENT:
I acknowledge that I have received and read a copy of the Enrollment Agreement (binding document) and catalog.
Initials:
This contract contains the entire agreement between the DIVERSE TRAINING CENTER and me, and no further modification or representation except as herein expressed in writing will be recognized. Initials:
GROUNDS FOR TERMINATION:
I agree to comply with the rules and policies and understand that DIVERSE TRAINING CENTER shall have the right to terminate this contract and my enrollment at any time for violation of rules and policies as outlined in the catalog. I understand that DIVERSE TRAINING CENTER reserves the right to modify the rules and regulations, and I will be advised of any and all modifications.
Initials:
GRADUATION REQUIREMENTS:
I understand that in order to graduate from the program and to receive my diploma, I must successfully complete the required number of scheduled clock hours as specified in the catalog and on the Student Enrollment Agreement, pass all written and practical examinations with a minimum of 70% average and satisfy all financial obligations to the School.
Initials:
EMPLOYMENT ASSISTANCE
I understand that DIVERSE TRAINING CENTER has not made and will not make any guarantees of employment or salary upon my graduation. DIVERSE TRAINING CENTER will provide me with placement assistance, which will consist of identifying employment opportunities and advising me on appropriate means of attempting to realize these opportunities.
Initials:
NOTICE TO PROSPECTIVE STUDENTS
DO NOT SIGN THIS CONTRACT BEFORE YOU READ IT, OR IF IT CONTAINS ANY BLANK SPACES. ALL SIGNERS HAVE RECEIVED AND READ A COPY OF THE BINDING DOCUMENT AND CATALOG, WHETHER HARD COPY OR ELECTRONICALLY.
YOU ARE ENTITLED TO AN EXACT COPY OF THE CONTRACT YOU SIGN. KEEP IT TO PROTECT YOUR LEGAL RIGHTS!
Student Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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Parent/Custodian Signature (If student under 18 years of age)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Accepting Official Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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DIVERSE TRAINING CENTER
2558 US Hwy 17-92N Haines City FL 33844 Suite E
Phone 407-225-5804
High School Attestation
have applied for admission to
(If applies)
Diverse Training Center Corp. I understand that one requirement for admission to Diverse
Training Center successful completion of high school or high school equivalency. I hereby
Certify that:
Student Information:
Full legal name during high school
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of School of (High school / GED)
Month & Year of Completion
By my signature below, I attest that the information provided above is true and correct to
the best of my knowledge. I further understand that any information provided to the
institution that is not accurate or truthful will result in the Termination of my studies, or
the denial of admission into the institution.
Student Signature
Please Print your Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
School Official's Signature
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DIVERSE TRAINING CENTER
2558 US Hwy 17-92N Suite E Haines City FL 33844
Phone 407-225-5804
HOME HEALTH AIDE - PROGRAM SCHEDULE
Student Name
Last 4 SSN
Start Date
Expected Graduation Date
Classes: Monday through Friday 9:00 am to 1:00 pm

WEEK	COURSE CODE	COURSE
1	HHA101	Introduction to Home Care and Health Care System
1	HHA102	Legal and Ethical Issues
1	HHA103	Communication and Cultural Diversity
1	HIV101	HIV/AIDS, Blood Born Pathogens and OSHA
1	HHA104	Safety and Body Mechanics
1	HHA105	Emergency Care
1	HHA106	Physical, Psychological and Social Health
1	HHA107	Anatomy of the Human Body in Health and Disease
1	HHA108	Human Development and the Aging Process
1	HHA109	Domestic Violence and Elder Abuse
1	HHA110	Death and Dying
1	HHA111	Transfer, Ambulating, and Repositioning
2	HHA112	Personal Care Skills
2	HHA113	CORE Health Care Skills and Resident's Rights
2	HHA114	Rehabilitation and Restorative Skills
2	HHA115	Medication Assistance and Technology in Home Care
2	HHA116	Clients with Disabilities
2	HHA117	Mental Health and Mental Illness
2	HHA118	Working with Newborns and Infants
2	HHA119	Common Acute and Chronic Conditions
2	HHA120	Maintaining a Healthy Environment
2	HHA121	Meeting the Nutritional Needs of the Patient
2	HHA122	Employability Skills
2	CPR101	CPR

Name

First NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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DIVERSE TRAINING CENTER

2558 US Hwy 17-92N Suite E Haines City FL 33844

Phone 407-225-5804
AUTHORIZATION TO OBTAIN EMPLOYMENT INFORMATION
I,
understand that the Florida Department of Education, Commission for Independent Education (CIE) requires student employment status to be reported annually, as well requires educational institutions such as Diverse Training Center to maintain employment information of its students on file for official onsite visits.
By signing this form, I authorize Diverse Training Center to obtain employment information from any current or future employer as long as the request is made before the expiration date indicated below.
I authorize any agency, person, or institution where I may be currently employed or may be employed in the future to provide employment information such as job title, employment start date, hours worked per week, beginning wage, current wage, job responsibilities, direct supervisor information, and employment performance.
I herewith release any agency, person, or institution from all liability to me for supplying employment information as authorized in this form.
I understand Diverse Training Center will maintain this information confidential and used solely for the purpose of reporting to government education agencies, as required by its regulations and law.
Expiration date of this authorization:

MonthDayYear
Student name
Program of study
Student signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Admissions counselor name
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Admissions counselor signature
DIVERSE TRAINING CENTER
2558 US Hwy 17-92N Suite E Haines City FL 33844
Phone 407-225-5804
DRUG-FREE STATEMENT AND CAMPUS SECURITY
Diverse Training Center is proud to offer its students and employees a safe, productive, and drug-free environment that supports quality education. Students and personnel are subject to all federal, state, and local laws as well as the regulations set forth by the institution as disclosed in the catalog, employee, and faculty handbook. Breach or violation of any of these regulations may result in disciplinary action or dismissal. The illegal use, possession, sale, or delivery of drugs or alcohol will not be tolerated and will be grounds for immediate dismissal.
Students and employees under the influence of illegal drugs or alcohol will be asked to leave school premises and could be permanently expelled. Possession of any weapon on campus is forbidden, with the exception of on-duty law enforcement officers.
Procedure for reporting emergencies, safety issues, crimes, or violations to school policies:
Students who observe violations of the institution's policies, emergencies on campus, or situations that might adversely affect campus safety, should immediately report those occurrences to their instructor or to the school administrative office. School employees are to immediately report to the school president or highest official present at the institution at the time of the incident, who will investigate the occurrence and complete an Incident and Accident Report Form and follow up as necessary. If appropriate, the local police/fire department should be notified. Incident Reports are permanently kept at the institution. Procedures for handling emergencies, safety issues, crimes, or violations to school policies follow the schools' Health and Safety Plan available to students and employees at the school's public website.
Student Name
Student Signature
Date
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School's Representative Name
School's Representative Signature
Date
DIVERSE TRAINING CENTER
2558 US Hwy 17-92N Suite E Haines City FL 33844
Phone 407-225-5804
EMAIL COMMUNICATION ACKNOWLEDGMENT
Email Address (as included in enrollment agreement)
example@example.com
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After completing the new student orientation listed above, I signed the enrollment agreement and received acopy of the following documents (please initial):
Program of Study
Student Name
Student Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
School's Representative Name
School's Representative Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DIVERSE TRAINING CENTER
2558 US Hwy 17-92N Suite E Haines City FL 33844
Phone 407-225-5804
VIDEO AND PHOTOGRAPH CONSENT AND RELEASE FORM
I ________________________________ authorize Diverse Training Center to publish videos
and/or photographs that include my name, likeness on the school's website or other web and media
outlets associated with Diverse Training Center or in connection with promotional, marketing, and
educational efforts by Diverse Training Center. I provide this consent without the expectation of
payment or any other type of compensation. I also acknowledge that this consent may be withdrawn
at any time by sending a written notice (via email or regular mail) identifying the specific image or video
that I want to be revoked. Upon receiving this notice, Diverse Training Center will have 30 days to take
down or obscure my likeness concerning the specific images or videos I have identified and requested
to be withdrawn.
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I release Diverse Training Center, its employees, and agents from any claims of harm and liability resulting from any distortion, blurring, or otherwise which may occur from making, showing, using, or distributing these photographs/video.
Print Name
Signature
Name of Parent of Guardian if Under 18
Signature of Parent of Guardian
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.
Email
example@example.com
Witness Name and Position
Witness Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DIVERSE TRAINING CENTER
2558 US Hwy 17-92N Suite E Haines City FL 33844
Phone 407-225-5804
BACKGROUND CHECK EMPLOYMENT REQUIREMENT ACKNOWLEDGMENT
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By signing this form, I confirm I will not hold Diverse Training Center responsible if I am unable to secure employment due to records in my background check, nor will I ask the school for a refund of the tuition paid.
Student name
Program of study
Student signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Admissions counselor name
Admissions counselor signature
DIVERSE TRAINING CENTER
2558 US Hwy 17-92N Suite E Haines City FL 33844
Phone 407-225-5804
PROSPECTIVE STUDENT APPLICATION
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DIVERSE TRAINING CENTER
2558 US Hwy 17-92N Suite E Haines City FL 33844
Phone 407-225-5804
ADMISSIONS INTERVIEW QUESTIONAIRE
HOME HEALTH AIDE PROGRAM
Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
1. What has prompted you to come back to school?
2. How do you feel about working with wounded patients, terminal patients, blood, needles, the elderly?
3. What are your goals for the next two-five years?
4. Do you mind standing for 6 hours or more?
5. Are you a people person?
6. Do you consider yourself to be a visual, auditory, or hands-on learner?
Student Signature
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DIVERSE TRAINING CENTER
2558 US Hwy 17-92N Suite E Haines City FL 33844
Phone 407-225-5804
BOOKS AND SUPPLIES FORM
Home Health Aide Program
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student Name
Last 4 SSN
Included below is the list of items you will receive as part of the books and supplies required for your program of study.

Included below is the list of items you will receive as part of the books and supplies required for your program of study.

Rows	Quantity	Item Description	Initials School Representative Item Provided	Student Initials Item Received	Date Received
1
2
3
4
5
6
7
8
9
10

I understand this form includes all books and supplies provided to me for this program of enrollment. I will write my initials and date next to each item in the list above I have received. I understand the materials provided to me as part of books and supplies are non-refundable since they are for personal use.
Student Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student Services Representative Name
Student Services Representative Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

SAP EVALUATION FORM
HOME HEALTH AIDE PROGRAM
Student Name
SAP Evaluation Date
Program Start Date
SAP EVALUATION PERIOD
1st period at 38 scheduled hours
2nd period at 75 scheduled hours
SAP CALCULATIONS
Scheduled Hours
Cumulative Attendance % (Actual hours attended/Scheduled hours)
Actual Hours
Cumulative Academic Grade (Average grade of all activities for the period)
SAP CRITERIA
Does the student meet the quantitative SAP criterion? (student attended at least 67% of hours scheduled for the period)
Does the student meet the qualitative SAP criterion? (student cumulative grade average is at least 70% (GPA 2.0))
SATISFACTORY ACADEMIC PROGRESS
Is the student making satisfactory academic progress? (student meets the two criteria listed above)
PROBATION
Will the student be placed on probation? (when the student does not meet SAP criteria)
Student will be on probation for the next evaluation period, from
to
Actions to be taken during probation to bring the student back to satisfactory academic progress (SAP) standards
Student Signature (only required if the student is not meeting SAP)
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

School's Official (Signature of official that completed this form)
DATE
SAP EVALUATION FORM
HOME HEALTH AIDE PROGRAM
Student Name
HOME HEALTH AIDE PROGRAM
SAP Evaluation Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Program Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SAP EVALUATION PERIOD
1st period at 38 scheduled hours
2nd period at 75 scheduled hours
SAP CALCULATIONS
Scheduled Hours
Cumulative Attendance % (Actual hours attended/Scheduled hours)
Actual Hours
Cumulative Academic Grade (Average grade of all activities for the period)
SAP CRITERIA
Does the student meet the quantitative SAP criterion? (student attended at least 67% of hours scheduled for the period)
Does the student meet the qualitative SAP criterion? (student cumulative grade average is at least 70% (GPA 2.0))
SATISFACTORY ACADEMIC PROGRESS
Is the student making satisfactory academic progress? (student meets the two criteria listed above)
PROBATION
Will the student be placed on probation? (when the student does not meet SAP criteria)
Student will be on probation for the next evaluation period, from
to
Actions to be taken during probation to bring the student back to satisfactory academic progress (SAP) standards
Student Signature (only required if the student is not meeting SAP)
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

School's Official (Signature of official that completed this form)
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
LEAVE OF ABSENCE (LOA) FORM
STUDENT INFORMATION
Name
Program of Enrollment
Last 4 SSN
Email
example@example.com
Phone
Format: (000) 000-0000.
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACT INFORMATION
Name
Email
example@example.com
Phone
Format: (000) 000-0000.
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
LEAVE OF ABSENCE REQUEST
Leave of absence start date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Leave of absence end date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Total number of days requested for leave of absence (counted as continuous calendar days)
Reason for requesting the leave of absence
I understand that I will be withdrawn from my program of enrollment if I do not return to school by the agreed date of / / (LOA end date).
Student Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
FOR SCHOOL USE ONLY
Student has already been approved for
days of LOA since

Student is requesting an additional
days to total
LOA days since
(12-month period starting with the first approved LOA date).

MonthDayYear
Decision:
MonthDayYear
to

MonthDayYear
LOA not approved. Reason
School's Official Name
Signature
Date

MonthDayYear
LOA Policy as Stated in School's Catalog
A Leave of Absence (LOA) may be granted for reasonable causes like personal and family illness, disability, or emergency for students with a reasonable expectation to return and resume their program of study.
An LOA must be requested in writing using the school's Leave of Absence Form prior to the beginning of the proposed requested leave. The request must include the reason for the request, the student signature as well as the date of request.
A leave of absence must be approved by Student Services and may not exceed 180 days. The number of days of an LOA are calculated as continuous calendar days, including weekends, holidays, and breaks.
When a student fails to return from the leave of absence as scheduled, they will be considered withdrawn, with the last day of attendance being the last day attended before starting the LOA.
The institution may grant a student multiple leaves of absence as long as the total number of days for all leaves does not exceed 180 days within a 12-month period which starts with the first day of the first LOA granted.
In the event of unforeseen circumstances, the institution may grant a leave of absence without having the request form in advance. The student would then need to complete the request form before the end of the LOA granting period.
Students that are not in regular attendance jeopardize the quality of their education. Therefore, a leave of absence is discouraged.
We value your feedback. Would you take a minute to complete the survey below?

program/course were current and relevant
Instructor Evaluation
The instructor for this program was effective and professionally delivered each class.
The instructor was always well prepared and on time for each class.
The instructor was available for clarifications, academic counseling, and advising.
COMMENTS
We appreciate any additional feedback you could provide to improve the quality of our programs of instruction.
Additional Feedback
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STUDENT ENROLLMENT AGREEMENT

STUDENT INFORMATION:

PROGRAM INFORMATION

FOR 5 OR MORE SCHEDULED PAYMENTS, YOUR TOTAL PAYMENT SCHEDULE WILL BE:

YOUR PAYMENT SCHEDULE WILL BE

CANCELLATION AND REFUND POLICY

ADDITIONAL TRAINING COST:

DELINQUENT STUDENT ACCOUNT BALANCE

ACKNOWLEDGEMENT:

GROUNDS FOR TERMINATION:

GRADUATION REQUIREMENTS:

EMPLOYMENT ASSISTANCE

NOTICE TO PROSPECTIVE STUDENTS

High School Attestation

Student Information:

HOME HEALTH AIDE - PROGRAM SCHEDULE

AUTHORIZATION TO OBTAIN EMPLOYMENT INFORMATION

DRUG-FREE STATEMENT AND CAMPUS SECURITY

NEW STUDENT ORIENTATION

VIDEO AND PHOTOGRAPH CONSENT AND RELEASE FORM

PROSPECTIVE STUDENT APPLICATION

ADMISSIONS INTERVIEW QUESTIONAIRE

HOME HEALTH AIDE PROGRAM

DIVERSE TRAINING CENTER

BOOKS AND SUPPLIES FORM

ADMISSIONS PROCESS CHECKLIST

Academic Advisement – Interview:

Admissions Representative Recommendation:

EMPLOYMENT VERIFICATION FORM

EMPLOYMENT INFORMATION

EMPLOYMENT CLASSIFICATION

EMPLOYMENT VERIFICATION METHOD

SAP EVALUATION FORM

HOME HEALTH AIDE PROGRAM

SAP EVALUATION PERIOD

SAP CALCULATIONS

SAP CRITERIA

SATISFACTORY ACADEMIC PROGRESS

PROBATION

SAP EVALUATION FORM

HOME HEALTH AIDE PROGRAM

SAP EVALUATION PERIOD

SAP CALCULATIONS

SAP CRITERIA

SATISFACTORY ACADEMIC PROGRESS

PROBATION

LEAVE OF ABSENCE (LOA) FORM

STUDENT INFORMATION

EMERGENCY CONTACT INFORMATION

LEAVE OF ABSENCE REQUEST

FOR SCHOOL USE ONLY

LOA Policy as Stated in School's Catalog

Instructor Evaluation

COMMENTS