Student Enrollment Form

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

Email *

example@example.com

How did you hear about us?

Are you over the age of 18? (applicants must be over the age of 18) *

Yes No

Do you have any visual or physical will make it difficult to learn a detailed craft like permanent cosmetics? *

No Yes

Select class below: *

Select class schedule below: *

Full-time Weekday Class (Monday - Friday 8am - 6pm) Weekend Class (Saturday & Sunday 8am -5pm) Advanced Class - (9am -5pm)

Choose class date - First Choice (100 Hour Fundamentals Class): *

May 3rd - May 14th, 2021 (full-time days) May 1st - May 30th, 2021 (weekend class) June 1st - June 12th, 2021 (full-time days) August 7th -September 5th (weekend class)

Choose class date - Second Choice (100 Hour Fundamental Class) *

May 3rd - May 14th, 2021 (full-time days) May 1st - May 30th2021 (weekend class) June 1st - June 12th 2021 (full-time days) August 7th - September 5th (weekend class)

Choose Advanced Class Date:

April 21st, 2021 (Business Credit Building & Social Media Marketing) May 19th, 2021 (Business Credit Building & Social Media Marketing) May 20th & 21st, 2021 (Blade to Shade)

Student Agreement: Please carefully read and agree to the following statements. If you have any questions or concerns, please contact the Academy prior to completing this form.

Phone: (540) 710-7600 or Email: info@novapmuacademy.com

It is my responsibility as the student to research all state and local regulations applicable to permanent cosmetics laws, regulations, and licensing in my locality. *

I understand

A deposit as designated above is required to reserve my place in the agreed upon class date for my training. These funds are required to be submitted with my enrollment form. The balance of the class fee is days 14 days prior to the first day of the designated class date. *

I understand

If an unforeseen emergency dictates that I cancel attendance in the class before the first day, or while the class is in progress, I will be offered a date in the future as agreed upon by to NoVA Academy of Micropigmentation & Permanent Cosmetic Makeup to complete the training course. NoVA Academy of Micropigmentation & Permanent Cosmetic Makeup does not offer refunds after the cancellation period. *

I understand

It is understood that if I have any special needs required to complete the on-site portion of the class, I must notify NoVA Academy of Micropigmentation & Permanent Cosmetic Makeup no later than two weeks in advance of the scheduled first day of class. Example: Latex allergy, non-latex gloves required. *

I understand

It is my responsibility to arrange and obtain a Certificate for an OSHA Bloodborne Pathogens Standard (BBP) and CPR & First Aid Class prior to the first day of class as required by law. We will provide you the list for Virginia approved vendors, in your enrollment packet, however all other states can contact the local Health Department or the Society of Permanent Cosmetic Professionals (www.spcp.org) for a referral to an OSHA trainer or an on-line BBP class. *

I understand

I understand that during class, the procedures I will be conducting are invasive. It is my responsibility to acquire the Hepatitis B series of immunizations prior to my class date, or I agree to decline the Hepatitis B inoculation process in writing. In any case, I hold Stacey Lynn Smith and/or her associates, and NoVA Academy of Micropigmentation & Permanent Cosmetic Makeup harmless for any accidental exposure to Bloodborne Pathogens during the on-site class session. *

I understand

Group class sizes are limited to six (6) students. This policy ensures that I will be properly supervised during the performance of hands-on procedures conducted in class. *

I understand

I understand that all training materials are copyrighted materials of NoVA Academy of Micropigmentation & Permanent Cosmetic Makeup and, may not be reproduced without prior written permission of the Director, Stacey Lynn Smith. *

I understand

I am responsible for my own transportation to and from class and for my own housing accommodations for the duration of the class. Lunch is daily and is taken between 12 noon – 1:00 pm. *

I understand

I agree to follow all instruction provided and will work cohesively with trainer and fellow classmates. *

I understand

I am responsible for bringing a camera or phone with camera that I am familiar with for the purpose of taking before and after photographs of my hands-on work performed during class. *

I understand

I understand that I must finish all hours of training including any pre-class study and study assignments, complete the competency written testing at a passing score of 85%, and perform satisfactory hands on procedures in order to receive a Certificate of Completion for the class. *

I understand

In the event a model cancels their scheduled appointments, I understand that the instructor will continue training by performing practical work, show permanent cosmetic videos, power point presentations, or assign practice work. *

I understand

I will receive a basic product kit at the beginning of the Fundamental Training Course that will include everything as outlined in the Syllabus. Any desired additional supplies or other tattoo device of my choice are separate and must be purchased independent of the student kit. *

I understand

I understand there is no guarantee of success in the permanent cosmetics industry, and that NoVA Academy of Micropigmentation & Permanent Cosmetic Makeup does not offer job placement services. *

I understand

It is my responsibility after the Fundamental Training Course to seek continuing education and advanced training as needed. *

I understand

NoVA Academy of Micropigmentation & Permanent Cosmetic offers post class support for a period of one year via email, phone, or at office during regular business hours. Post class support may include verbal/written advice for student’s procedures or any permanent cosmetics topics. *

I understand

Attendance Policy: Students should plan to attend the training class daily on the exact dates scheduled and/or prearranged for her/his Training Class. Students are expected to arrive on time each day and stay until the end of class time each day. If the student is tardy, class time will be made up during lunch hour or at end of the class day. If a student is tardy three times during the training course, a Certificate of Completion will not be awarded until tardiness times are made up. In the event student must miss a portion of the training class due to illness or other unforeseeable situations, a makeup day(s) will be scheduled accordingly per the student’s and instructor’s schedules and mutual agreement. In the event, student cancels her/his enrollment in a training class, either prior to the beginning of, or during the training course, the student and instructor shall refer to the Cancellation Policy. Students are expected to abide by all written policies of NoVA Academy of Micropigmentation & Permanent Cosmetic Makeup. Failure to do so may result in termination of her/his enrollment in the Fundamental Training Course if the violation of the policy has not been resolved.

Signature

Clear

DRESS POLICY: In all training classes, the dress policy is dark colored scrubs (no prints), or comfortable dark colored pants, dark colored shirt, and comfortable shoes. Part of the student’s class activity involves practicing with various machines, equipment, and pigment colors on practice pads. The pigments used in permanent cosmetic tattooing may stain clothing, therefore wear appropriate clothing for class. During practice activities and the hands-on practical portion of the training course, all disposable personal protective equipment including aprons and Nitrile gloves will be provided to students.

Signature

Clear

CONDUCT POLICY: The purpose of this policy is to set forth standards of conduct to address unacceptable behavior conduct and related circumstances in all Training Classes. The following list is not all-inclusive but is intended to illustrate the minimum expectations for acceptable classroom conduct and performance. Students who contribute to the success of a training course:

1. Report to class as scheduled and seek approval from their supervisors in advance for any changes to the established class schedule, including the use of leave and late or early arrivals and departures.

2. Perform assigned class activities and home study assignments.

3. Follow all instructions provided and work cohesively with and demonstrate respect to class instructor and fellow classmate.

4. Finish all hours of training including any pre-class and evening home work-study assignments, complete the competency written testing at a passing score of 85%, and perform satisfactory hands-on procedures in order to receive a Certificate of Completion for the class.

5. Resolve class-related issues and disputes in a professional manner. A first offense/ violation of Conduct Policy will result in verbal reprimand; a second offense will be written reprimand; a third offense may result in dismissal for repeated violation of policy. If the result is dismissal, refer to the Cancellation Policy.

Signature

Clear

CANCELLATION POLICY: If the student has enrolled in the training course and has been accepted by NoVA Academy of Micropigmentation & Permanent Cosmetic Makeup, and the student cancels the enrollment agreement within three (3) days of signing the Enrollment Agreement, then the student is entitled to a full refund of monies paid, less a $150.00 processing fee. The cancellation period shall not be less than three (3) days, exclusive of Saturdays, Sundays, and holidays. NoVA Academy of Micropigmentation & Permanent Cosmetic Makeup does not offer full refunds after the cancellation period. In the event, the student is unable to attend the scheduled class due to unforeseen circumstances, then alternative future dates will be made available.

Signature

Clear

I have read and thoroughly understand this Student Enrollment Application and Agreement. I have had the opportunity to have all of my questions regarding the class answered prior to enrolling in any Permanent Cosmetic Training Class offered by NoVA Academy of Micropigmentation & Permanent Cosmetic.

In addition, I understand that I am not officially enrolled until the enrollment deposit is paid.

Signature *

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Date *

Date

Upload a photo of Driver's License, State or Government Identification *