Payment Agreement Form

Advanced Laser Institute

919 W. Gray Street Houston, TX 77019

Your Name*

Your Address*

Your Phone Number*

Apprentice-In Training License # (If Applicable)

Social Security Number*

Your Email Address*

Enter Email Confirm Email

Emergency Contact Name:*

First Last

Emergency Contact Phone Number:*

Emergency Contact Number:

Upload A Copy Of Your Driver’s License*

Max. file size: 5 MB.

Upload Your High School Diploma/GED Or A Higher Degree*

Max. file size: 128 MB.

Upload you CPR Certification*

Max. file size: 1 MB.

If you are not CPR Certified, please upload a note stating that you will be enrolling in the course. This course is not provided by Advanced Laser Institute.

40 hr. Apprentice-In Training (Payment Plan)

**Important: Please check the box next to each payment options you agree to, including the total amount. If you are not registering to the following course, please select the “Decline Payment Option” checkbox.

Payment Plan for Apprentice-In Training: $828*

1st Payment $276 Due Today
2nd Payment $276 Due on or before 15 days of Enrollment
3rd Payment: $276 Due on or before 30 days of Enrollment
Total: $828
Decline Payment Option

100 Treatment Practicum (Payment Plan)

**Important: Please check the box next to each payment options you agree to, including the total amount. If you are not registering to the following course, please select the “Decline Payment Option” checkbox.

Payment Plan for 100 Treatment Practicum – $870*

1st Payment $370 Due at the time of Enrollment
2nd Payment $250 Due on or before 15 days of Enrollment
3rd Payment: $250 Due on or before 30 days of Enrollment
Total: $870
Decline Payment Option

METHOD OF PAYMENT: Please choose from the following options:*

[3.9% fee is applied to all major credit card payments] Any holder of this consumer credit contract is subject to all claims and defenses which the debtor could assert against the seller of goods or services obtained pursuant hereto or with the proceeds hereof. Recovery hereunder by the debtor shall not exceed the amounts paid by the debtor hereunder. “

Payment Plan Authorization and Consent*

I acknowledge and agree to the following terms:

Payments will be automatically charged every 2 weeks until the full payment is made.

The full balance must be paid within 30 days of enrollment.

The certificate of completion and all required documents will be issued once full payment has been received.

Consent to Photograph for Social Media*

I Consent: I agree to be photographed and/or recorded. I understand that these images and videos may be used in promotional materials, including social media, websites, and other marketing platforms.
I Decline: I do not wish to be photographed or recorded. Please ensure that my participation is not captured in any images or videos.

Please select one of the options listed above. (This section applies to the hands-on training.)

I acknowledge receipt of this school catalog and a copy of this completed enrollment agreement as a:*

HARD COPY
ELECTRONIC COPY
WEBLINK

If I did not receive a hard copy of the catalog and/or this enrollment agreement, I understand the school will provide them at my request. If I did not receive a hard copy of the catalog and/or this enrollment agreement, I understand the school will provide them at my request.

Consent to Policies, Procedures, Refund and Cancellation Terms*

I agree to the policies and procedures.

I certify that I have been provided all the information above prior to my enrollment. By signing this document, I acknowledge receipt of this school catalog and a copy of this completed enrollment agreement.

By providing my electronic signature below, I acknowledge that this Enrollment Agreement becomes effective on the date listed below.

CANCELLATION POLICY:
A full refund will be made to any student who cancels the enrollment contract within 72 hours (until midnight of the third day) after the enrollment contract is signed. The school will not retain more than $100 in any administrative fees charged, as well as items of extra expense that are necessary for the portion of the program attended and stated separately on the enrollment agreement. No Refunds: Cancellations requested after 3 days from the date of enrollment are not eligible for refunds.

REFUND POLICY:
Refund computations will be based on the period of enrollment computed on basis of course time (40 hrs). 2. The effective date of termination for refund purposes will be the earliest of the following: (a) the last date of attendance; or (b) the date of receipt of written notice from the student. 3. If tuition and fees are collected in advance of entrance, and the student does not enter school, not more than $100 shall be retained by the school. 4. If the student fails to enter the program, withdraws, or is discontinued at any time before completion of the program, the student will be refunded the pro rata portion of tuition, fees, and other charges that the number of class hours remaining in the program after the effective date of termination bears to the total number of class hours in the program. 5. A full refund of all tuition and fees is due in each of the following cases: (a) an enrollee is not accepted by the school; (b) if the program of instruction is discontinued by the school and this prevents the student from completing the program; or (c) if the student’s enrollment was procured as a result of any misrepresentation in advertising, promotional materials of the school, or misrepresentations by the owner or representatives of the school. 6. REFUND POLICY FOR STUDENTS CALLED TO ACTIVE MILITARY SERVICE A student of the school or college who withdraws from the school or college as a result of the student being called to active duty in a military service of the United States or the Texas National Guard may elect one of the following options for each program in which the student is enrolled: (a) if tuition and fees are collected in advance of the withdrawal, a pro rata refund of any tuition, fees, or other charges paid by the student for the program and a cancellation of any unpaid tuition, fees, or other charges owed by the student for the portion of the program the student does not complete following withdrawal; (b) a grade of incomplete with the designation “withdrawn-military” for the courses in the program, other than courses for which the student has previously received a grade on the student’s transcript, and the right to re-enroll in the program, or a substantially equivalent program if that program is no longer without payment of additional tuition, fees, or other charges for the program other than any previously unpaid balance of the original tuition, fees, and charges for books for the program; or (c) the assignment of an appropriate final grade or credit for the courses in the program, but only if the instructor or instructors of the program determine that the student has: (1) satisfactorily completed at least 90 percent of the required coursework for the program; and (2) demonstrated sufficient mastery of the program material to receive credit for completing the program. 7. Refunds will be totally consummated within 60 days after the effective date of termination.

ELECTRONIC SIGNATURE:

Your Name*

Date*

Available Payment Plan Options

Advanced Laser Institute

40 hr. Apprentice-In Training (Payment Plan)

100 Treatment Practicum (Payment Plan)

ELECTRONIC SIGNATURE:

Enrollment Form