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PIC**** All Rights Reserved. The information here is confidential and strictly intended for the use of Prisma International Corporation staff and authorized parties. This is a controlled copy. PRISMA INTERNATIONAL CORPORATION

A World of Solutions

STUDENT REGISTRATION FORM

PLEASE COMPLETE PAGES (Front and Back) DATE / / D D / M M M / Y Y Y Y

Name LAST FIRST MIDDLE

Present address NUMBER STREET CITY STATE ZIP CODE

Referral Source Craiglist CCHCP Direct Mail

Radio/TV Google Facebook

Twitter LinkedIn Other/Referral

Social Security No. – –

LAST 4 DIGITS FOR ID PURPOSES ONLY

Telephone Personal E-mail address Emergency Contact Telephone Name Relationship Do you have any life-threatening allergies? No Yes If so, reaction and emergency contact REACTION LINKEDIN FACEBOOK TWITTER When and where would you like to take your class? Mark an X: Customized/Virtual NC MA FL MONTH JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Mark One (X)

Language Combination English / (For what language should we order your glossary)? Please refer to our calendar of training events on our website for the latest information Are you interested in? Private Lesson Refresher Course Are you interested in? CCHCP Bridging the Gap

Is your fee waived? Flash Coupon Facebook/Twitter Unemployment Corporate Discount Other Why are you interested in taking a class at Prisma International Corporation?

Personal Goal Professional Development Corporate Requirement Other If 5 of your referrals book a class together, that would waive your class registration fee! Were you aware of this? No Yes We have career opportunities for our graduates. Would you like to receive more information upon successful completion of the course? No Yes

Photo Release Authorization (Signature) / / D D /M M M / Y Y Y Y By initialing this clause, I authorize free use of photographic image for marketing purposes: website, brochures. 2015 REVISION - PAGE 2

PIC1009 All Rights Reserved. The information here is confidential and strictly intended for the use of Prisma International Corporation staff and authorized parties. This is a controlled copy. PRISMA INTERNATIONAL CORPORATION

A World of Solutions

PLEASE READ CAREFULLY and INITIAL EACH PARAGRAPH

I hereby release from liability PRISMA INTERNATIONAL CORPORATION and its representatives for seeking, gathering, and using such information to make admission decisions and all other persons or organizations for providing such information.

I hereby understand PRISMA INTERNATIONAL CORPORATION shall not be held liable for any type of liability, including but not limited to student’s behavior while on site liability, damage or loss of student’s property liability, liability within the Company premises included but not limited to company surrounding areas and building, and company parking space. I understand that any misrepresentation or material omission made by me on this application for admission will be sufficient cause for cancellation of this application or immediate termination of services rendered, whenever it may be discovered. I acknowledge that there is a specified length and time for services and that this application does constitute an agreement or contract for services upon payment is received. Accordingly, either I or Prisma International Corporation can terminate the relationship at will, with or without cause, at any time before Prisma International Corporation confirms your class registration and seat booked in writing; as there is no violation of applicable federal or state law.

I acknowledge and understand that I will cancel my registration if no payments have been disbursed to Prisma International Corporation. I also acknowledge that I understand if costs are incurred by Prisma International Corporation for booking hotel/accommodation/conference room for this class that requires a minimum of participants to hold the class; that my registration fees are forfeit, if I am unable to attend the class for which I register (example: signing for a conference you cannot attend anymore). I acknowledge and understand that the payments are due before or on the first day of class and no refunds are available. If you cannot make the class, your class registration fees may be applied for the next classes available within the same calendar year on your registration form; only if any of these cases apply: medical emergency which requires a medical provider work/school note, loss of immediate family member, sudden relocation, or job loss.

PRISMA INTERNATIONAL CORPORATION is an equal employment opportunity employer and service provider. We adhere to a policy of making admissions decisions without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, age, height, weight, or disability. Thank you for completing this application form and for your interest in our business. / / D D /M M M / Y Y Y Y Applicant Signature Print Name Date

WOULD YOU LIKE US TO SHARE YOUR EXPERIENCE AND OUR SERVICES TO YOUR CLOSE FRIENDS? Provide 3 at least (Optional)

NAME RELATIONSHIP CONTACT INFO (PHONE/EMAIL)