NCLEX hurst review complete workbook

INSTRUCTIONS IF you have pre-registered for this review prior to the first day of class via the internet or by mail or if you have attended a live review in the past AND you have paid for the class in full or you have attended Hurst Review before, please turn in the following information to your instructor before the end of the first day of class: 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. 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. 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. 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 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: NOTICE You must select one of the following by putting your initials in the blank: 1. If I am unsuccessful on the boards, I would like to end my relationship with Hurst Review Services and receive my money back for having taken the class. I understand that I will be refunded all of my money except for a $75 administrative fee. I further understand that it is my responsibility to notify Hurst Review Services within 2 weeks of receiving my board scores and that I must send the following information to Hurst Review Services’ office in order to receive my refund. You will not receive a refund until all items listed below have been received by Hurst Review Services. a. The postmarked envelope that my results were sent in b. My candidate report c. All material received from Hurst Review Services (student book, CD, and DVD). 2. If I am unsuccessful on the boards, I would like to continue my relationship with Hurst Review Services as a remedial student and receive help in passing my boards. I understand Hurst Review will be committed to my passing and will assist me until I am successful. I must agree to make the initial contact with Hurst Review and stay in touch on a regular basis (every 45 days) until I pass boards. After 12 months (starting from the date the student takes the class) the remedial student will be charged $50.00 every 90 days if they are still participating in the remedial process. 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) *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: Total amount to be charged: Signature: CHECK INFORMATION *Fill out the following section ONLY if you are paying by Check Checks may be made payable to: Hurst Review Services ** Please be sure your name is printed in the “memo” blank on the bottom of the check** You can write one check for your balance dated the first day of the class. OR If you are participating in our payment plan, you will enclose 2 checks in your envelope. This is the only form of payment plan that we offer… so if you wish to participate in the payment plan you will need to write two separate checks. -The first check will be in the amount of half of your balance dated the first day of the class and a second check for the amount of the other half of the balance dated ONE month later. (Example: If the first day of class is on January 3, 2009 AND you have a remaining balance of $300.00, you will write ONE check for $150.00 dated January 3, 2009 and then a SECOND check for $150.00 dated February 3, 2009.) All checks must be turned in the first day of class. Checks will not be cashed until the date printed on the check. If you are writing a check(s), you must complete the following section: This is your authority to obtain a Credit Bureau on me in the event circumstances should arise (i.e. stopping payments; Non-sufficient Funds checks, closed accounts, skip tracing, and etc.) Signed this day, (today’s date) Signature: Social Security Number: Witness: Anyone who is writing a check(s) has to read the following statement, understand it, and remember it!! If you write a check and then close the account or the check is returned due to insufficient funds or other reasons… it is considered to be “issuing a false instrument.” In other words, it is illegal! Any and all measures will be taken to collect on the check. If a criminal affidavit needs to be issued, it will. The District Attorney in your area will be notified for collection and prosecution. Your District Attorney will be given the legal document (the bad check). The Board of Nursing and your employer will be alerted to the fact that you are participating in illegal activity. Hurst Review Services has authorized the District Attorney’s Office to institute collection proceedings viand then further authorized to sign a criminal affidavit on our behalf.Hurst Review Services