Copy of hurst_review_complete_workbook (1)

Please print on the outside of the envelope (that will be provided to you by your Hurst Review instructor) the following information: 1. Name 2. Address 3. Phone number 4. Name of Nursing School 5. Graduation Date 6. Print: “Paid in Full” on the outside of your envelope—ONLY if you are paid in full PRIOR to the first day of class. IF you have pre-registered for this review prior to the first day of class via the internet or by mail AND you have a remaining balance, please turn in the following information to your instructor before the end of the first day of class: You must be paid in full the first day of the review. 1. Please print on the outside of the envelope (that will be provided to you by your Hurst Review instructor) the following information: 1. Name 2. Address 3. Phone number 4. Name of Nursing School 5. Graduation Date 6. Print the method of payment on the outside of your envelope— (Do not put “paid in full” on the outside of your envelope if you are paying off your balance. Put the form of payment). □ If you are paying by credit card print “credit card” on the outside of your envelope. □ If you are paying by check (s) please print “check” on the outside of your envelope. □ If you are paying by cash, please print “cash” on the outside of your envelope. 2. Complete the form marked: Payment Information a. If you are writing a check(s), checks are to be made payable to Hurst Review Services. Hurst Review Services i 3. Once you have completed the Payment Information form, place the form and the method of payment (cash, check(s) or credit card information) in the envelope and return it to your instructor. Instructions IF you have NOT pre-registered for this review prior to the first day of class via the internet please turn in the following information to your instructor before the end of the first day of class: You must be paid in full the first day of the review. 1. Please print on the outside of the envelope (that will be provided to you by your Hurst Review instructor) the following information: 1. Name 2. Address 3. Phone number 4. Name of Nursing School 5. Graduation Date 6. Print the method of payment on the outside of your envelope □ If you are paying by credit card print “credit card” on the outside of your envelope. □ If you are paying by check(s) please print “check” on the outside of your envelope. □ If you are paying by cash, please print “cash” on the outside of your envelope. 2. Complete the forms marked: General Student Information AND Payment Information AND Notice for the Student. 3. Once you have completed all 3 forms, place all forms and the method of payment (cash, check(s) or credit card information) in the envelope and return it to your instructor. Instructions General Student Information ***ONLY COMPLETE THIS FORM IF YOU HAVE NOT PRE-REGISTERED FOR THIS REVIEW*** Name: Gender: Address: Phone Number(s): (Home) (Cell) E-mail Address: Are you currently enrolled in a nursing program? Yes or No School of Nursing: Graduation Date: Place of Employment (if known): Is this your first time to take the boards? Yes or No (please circle one answer) If not, how many times have you taken the boards? Have you taken a NCLEX® Review class prior to attending Hurst Review? Yes or No (please circle one answer) If yes, which NCLEX® Review class did you attend? ***ONLY COMPLETE THIS FORM IF YOU HAVE NOT Instructions PRE-REGISTERED FOR THIS REVIEW*** NOTICE FOR THE STUDENT I, the undersigned , do hereby agree not to reproduce or transmit in any form or by any means (electronic, mechanical, photocopying, or otherwise) any part or parts of the course or course materials offered by Hurst Review Services. I understand this course is designed and presented to assist in my passing of the NCLEX® and agree not to divulge any teaching techniques, topics, sources, or any other data used within this class to anyone. I do hereby further understand that any infraction of this notice will result in prompt litigation. SIGNED: PARTICIPANT WITNESS: The Hurst Review Guarantee We guarantee that a students’ first NCLEX® attempt will be successful if the student has completed either the Hurst Live, Online, or DVD review in its entirety, and attempts the NCLEX® within 6 months of graduation from an accredited school of nursing. If such student is unsuccessful, Hurst will provide, at the student’s choice, either: 1) Our one-time 45-day remediation course which must be completed within 1 year of student’s graduation date. OR 2) A full refund, less our $75 administration fee. To receive a refund, student must: ‐ Not have taken more than 2 reviews (Live, Online or DVD in any combination) ‐ Notify Hurst within 2 weeks of receiving NCLEX® failure notice ‐ Provide postmarked envelope of NCLEX® failure notice (copy or actual) ‐ Return all course material provided including student book, CD & DVD. This policy will be strictly enforced. We reserve the right to amend or change any policy at our sole discretion. ( ) I acknowledge that I have read the guarantee policy and will be bound by its provisions. Signed: PARTICIPANT Payment Information I am paying by: (please select the method of payment) Cash Check (see page vi) Credit Card (complete bottom of page) Instructions *If you are paying with cash you will receive a receipt by the end of the review from your instructor. *If you are paying with a check or credit card, your bank statement or credit card statement will serve as your receipt. My hospital is reimbursing me for this class or is paying for this NCLEX® review class. Yes or No (please circle one answer) If yes, please provide the following information: Hospital Contact person If documentation is required for reimbursement or proof of attendance, please have your Hurst Review instructor complete the proof of attendance letter on page vii. Notice I, , do hereby agree to pay Hurst Review Services in full for the NCLEX® review course which I participated on (please put the date of attendance). The terms we agreed upon are outlined above, I understand that if I do not pay according to the plan agreed upon, my wages will be garnished if necessary and any and all legal measures will be taken within a court of law. Signed : ( Participant) Credit Card Information *Fill out the following section ONLY if you are paying by Credit Card Card Holder Name (please print clearly): Billing Address: Phone Number: Type of credit card (please circle one): Visa MasterCard Discover Card Number: Expiration Date: