M/C Insights, Inc.

Redirect Your Life
Enrollment Form

All entries are required
Name:		Address:
City:		State:		Zip:
Home Phone:		Work Phone:
DOB:		E-mail:
Date of Course:		Enrolled By:
Tuition:		Deposit:
Balance:		To be paid on or before:

I have read the Terms, Informed Consent Agreement and Refund Policy below:

Terms
I am aware that breaking the agreement would greatly minimize the value I would gain from the course and, therefore, I will be responsible for overcoming any circumstances which would prevent me from keeping this agreement. I agree to attend, in their entirety, alI sessions of the course. I agree to be on time for each session. I agree to return the Student Information Sheet and this signed Enrollment Agreement Form within 5 days. I agree not to take any non-prescription drugs or alcohol within 24 hours of any session. As a participant in this course, I agree to respect the confidentiality of all participants and their remarks.
Informed Consent Agreement
I understand that this course is educational and NOT psychotherapy or a substitute for psychotherapy. I understand that in addition to the benefits, there is always the risk of emotional and/or medical contingencies in such a group experience. I assume the risk, by this consent of any accident or injury to myself during this course, or inflicted by me during the course, and hereby release the instructors from any liability thereof. I take responsibility for consulting with a medical doctor prior to participating in the course concerning any known or potential emotional or physical conditions I have or may have, for the purpose of getting permission to participate. I assume the risk, by this consent, of any illness during the course, and hereby release the instructors for any liability thereof. I hereby authorize the instructors to take any reasonable steps on my behalf in the case of an accident, injury, or illness including, but not limited to, first aid, doctor, nurse and/or ambulance services, etc. I agree to be liable for the cost of any such actions taken on my behalf, and hereby release the instructors for any liability thereof. If I have had serious emotional problems or have been hospitalized for emotional problems or am currently under the care of a psychologist or psychiatrist, I understand that it is required that I attend the program only with the written permission of my therapist.
Refund Policy
After the course, if you are dissatisfied, your tuition will be refunded provided all of the following conditions have been met: You have been in attendance the full time for each of the sessions of the course. You have participated in all the exercises of the course. You have met with the instructors. You have submitted a request for a refund, stating the reasons for your dissatisfaction, within seven days of the last session of your course.