COPY AND PASTE THIS REGISTRATION FORM INTO AN EMAIL TO: [email protected]

You will be contacted by phone, and email when this form is received.

Course Registration Form

Name:

Mailing Address:

Phone Number:

Work Phone: Cell Phone:

E-mail Address:

Name of Class:

Date(s) of Class:

Form of Payment:

Credit Card Number:

Expiration Date                                                 3 digit code on back of card

Have You Taken A Class With us Before?

If so, what class?

White Cloud Institute, PO Box 31996 Bellingham, WA 98228

E-mail us at: [email protected] or call 505 670-3538

We can take a credit card for payment over the phone.

In order to guarantee your space in class a $75 non refundable deposit is due when you register. Full tuition is due 2 weeks prior to class. No refunds once a class begins

White Cloud Institute

Student Consent Form

In agreeing to register for classes with White Cloud Institute, you are verifying that you have not been sick in the past 2 weeks, or to the best of your knowledge, been in contact with anyone who is sick.

If you have any of the following symptoms please stay home to rest.

• Cough

• Fever

• Shortness of breath, difficulty breathing

• Muscle aches

• Sore throat

• A general feeling of being unwell or confused

Loss of taste or smell

Skin Rash

White Cloud Institute guarantees that the classroom and all equipment will be cleaned and sanitized before every class. I also guarantee that, as your instructor, 1 am healthy and following all Covid 19 guidelines. I will wear a mask during class and you must bring a mask with you to wear during class. Hand sanitizer will be available in class.

• New Cancellation Policy

Amid the ongoing uncertainty of COVID-19, I have modified my cancellation policy to offer greater flexibility to students. I hope this will alleviate any stress and hesitation you have about an upcoming class. If you need to reschedule or cancel if you are not feeling well, I understand and request for you to please contact me as soon as possible.

• I will be contacting you within 2-3 days after class to inquire about your health. If you have become ill I will take appropriate actions to protect myself and other students.

Acknowledgement and Release

I hereby acknowledge that I have read the foregoing White Cloud Institute Student class Consent Form. I release Caryn Diel from any and all claims of malpractice, non-disclosure, or lack of informed consent. I freely assume any and all risks, whether presently contemplated or hereinafter discovered.

Signed___________________________________________Date_________