Enrollment Forms
First 4* Classes Free. No Enrollment Fees. Pay Nothing Until Week 5. Enroll Today and Proof of Enrollment will Be Emailed to You Within 48 Hrs. Have questions? Call 539-777-0753. DO NOT FILL THESE FORMS OUT TWICE. DO NOT FILL THESE FORMS OUT IF YOU ARE A VICTIM of domestic violence. These classes are for Domestic Violence Offenders only.
Name
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First Name
Last Name
Middle Name
Email (Type it CAREFULLY & double check it)
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
I Certify I have never filled out these Enrollment Forms. (Do NOT Fill these FORMS OUT TWICE. Go to Class 1 if you have already filled out these forms.) Sign your name below to verify you have NEVER filled out these Enrollment forms.
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Your Enrollment is Free & the first 4* classes are Free. No payment will be due until week 5. You will receive Proof of Enrollment once we review your enrollment forms. Once you submit these Enrollment Forms WATCH YOUR EMAIL for Instructiions & your Proof of Enrollment Letter that you may print. (Please note we only accept 1 person per case/address, if you and your partner both need classes they will need to enroll at an alternative agency). On the line below please TYPE out YOUR entire FULL NAME--FIRST, MIDDLE, LAST as you want it to appear on your Proof of Enrollment Letter
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Enter your CASE NUMBER (If you do not have it with you right now or do not have one you may still complete your Enrollment forms, just type 0000 then you may email your Case Number to us ASAP to be included on your Enrollment Letter. Classes are educational in nature and are a not a substitute for counseling or therapy. These classses are for DV Offenders. THESE CLASSES ARE NOT FOR DV VICTIMS. (Please note that We DO NOT SERVICE Oklahoma & Washington state, they DO NOT allow online DV classes. California requires prior approval for online classes. Also, if you case involves CPS/DHS/Children these are not the correct classes, please contact the courthouse in your local area to complete your classes.) Type your CASE NUMBER BELOW.
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HOW MANY TOTAL NUMBER OF CLASSES do you need to complete? Type UNKNOWN if you don't know how many classes you need to complete. PLEASE DO NOT write the number of months--write the Total Number of Weekly Classes you need to complete. Our minimum number of classes is 16 classes to receive the first 4 classes free. If you need less than 16, the classes can be taken individually and are 21.00 per class. NOTE: 16 is a random number we selected. Do NOT write 16 unless someone over your situation gave you that specific number. Most situations required 26 or 52 classes):
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In accordance with the Uniform Electronic Transactions Act (15 US Code, Section 7001) I agree that typing my name on these enrollment forms has the same force and effect as having signed my signature. I also understand I may print a copy of this document. TYPE YOUR NAME below in agreement.:
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DESCRIBE the incident leading to you taking these classes / what SPECIFICALLY (pushing, punching, choking,etc) are you accused of and WHO was it toward (wife, brother, cousin, boyfriend, etc)? Please note Our classes are ONLY for the offender and not for cases involving children. (Please DO NOT WRITE "None" or "domestic violence" or one word---be specific & DO NOT ENROLL IF YOU ARE THE VICTIM.)
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FEE POLICY: (PLEASE SIGN BELOW) FEE POLICY: (PLEASE SIGN BELOW) The enrollment fee is WAIVED for online class participants. Your first 4 classes are free if you are doing our minimum program of 16 classes or more. No payment will be due until week 5. This is intended to give you time to save money & prepare for your class fees which will start on week 5. Starting with week 5 each class is 21.00 and one class will need to be completed each week. (If you will be doing less than 16 classes, each class can be purchased individually @ $21/class) TYPE YOUR NAME below in agreement and acceptance of the Fee Policy:
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CLASS PARTICIPANTS RIGHTS: (PLEASE SIGN BELOW ) Each class participant has the right to be treated with respect and dignity. This shall be construed to protect and promote human dignity and respect for individual dignity. Each class participant has the right to receive services without regard to his or her race, religion, sex, ethnic origin, age, degree of disability, handicapping condition, or legal status. Each participant has the right to refuse to participate in any research project or medical experiment without informed consent, as defined by law. A refusal to participate shall not affect the services available to the participant. Each class participant has the right to assert grievances with respect to any alleged infringement of these stated rights, or any other subsequently statutorily granted rights. No class participant shall ever be retaliated against, or subject to, any adverse conditions or services solely or partially because of having asserted her or his rights as stated in this section. Each class participant has the right to review his or her own records. Each class participant has the right to know why services are refused and can expect an explanation concerning the reason he or she was refused certain services. If you feel these rights have been violated in any way, please contact the Transformations BIP LLC Program Director, Deborah Farber. I understand the classes are for educational purposes only and are not a substitute for counseling or therapy. I understand it is my responsibility to ensure online classes are accepted in my situation and that I have 60 days from the date of enrollment to request a full refund of fees paid. TYPE YOUR NAME below to confirm you understand:
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ABSENCE POLICY: (PLEASE SIGN BELOW) I understand that in order to remain enrolled in classes it is directly dependent upon my COMPLETING ONE SESSION PER CALENDAR WEEK and submitting it by SUNDAY NIGHT. You may submit your class anytime day or night but we must receive it by Sunday night to avoid an absence. I undertand If I fail to complete at least One (1) class per week it will count as an absence and if I have excessive absences, I may be required to restart classes. TYPE YOUR NAME below to acknowledge you understand:
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VICTIM SAFETY POLICY: (PLEASE SIGN BELOW) It is the policy of Transformations BIP LLC for you to sign below to acknowledge consent to contact the victim and /or former partners as necessary if there is imminent threat or danger to the partner or victim safety. By signing below, I agree to enter classes with full cooperation and participation. I understand what to expect from and I also acknowledge I understand the 60 day refund policy, Participant Rules and Requirements; I understand COPIES OF MY QUIZZES CANNOT BE PROVIDED to third parties but Compliance Updates can be requested at any time and I understand I need to allow 48 hrs to receive my compliance update. Victim/partner may be notified when: there appears to be imminent threat or danger to the victim's/partner's safety (mandatory). In accordance with the Uniform Electronic Transactions Act (15 US Code, Section 7001) I agree that typing my name has the same force and effect as having signed my signature. TYPE YOUR NAME in the box below to acknowledge you understand:
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Do you currently have a Victim Protective Order against you? Yes or No? If yes how long is the protective order for--when does it expire? What is the case number? (List whatever information you have)
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Are you currently living with your partner? Do you have children living in the home? How many children?
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CLASS GRIEVANCE: (PLEASE SIGN BELOW) The Director of Transformations BIP LLC maintains the responsibility for coordination of Transformations BIP LLC Grievance Policy and to make decisions regarding the resolution of grievances. Transformations BIP LLC classes were created by a Professional Counselor however the online program itself is not state approved as there is no national governing body. • The classes are for educational purposes only and are not a substitute for counseling or therapy. If the partipant has a concern they will present the grievance to the Director. Resolution of the grievance shall be obtained in a timely manner not to exceed 14 days and the participant will receive a response. I understand the above Grievance Procedures and can print a copy of this form. In accordance with the Uniform Electronic Transactions Act (15 US Code, Section 7001) I agree that typing my name has the same force and effect as having signed my signature. TYPE YOUR NAME below in agreement:
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CONFIDENTIALITY: (PLEASE SIGN BELOW) You are joining an Educational class and not a therapeutic program, and therefore you will not have the same level of confidentiality that would be guaranteed in mental health services. The classes are educational in nature and are not therapy or counseling services. TBL will not promise confidentiality with respect to: your current partner; the person toward whom your crime was committed against; any past partner with whom you have children; any state court's probation department; any state's child protective service if your participation in the program is mandated or requested by that service; your local police department/parole officer/attorney; any state's public defender that applies to your specific case; any program for battered victims in the area where you live or where your current or ex-partner lives; any state's office of the Intervention records review team; and any individual we believe is in imminent danger or serious harm. With respect to the above individuals and/or institutions and/or agencies, TBL will release information as it considers it reasonable, prudent or necessary to do so in order to promote victim safety and accountability and to avoid any harm coming to the victim or their children. TYPE YOUR EMAIL ADDRESS below to confirm you understand:
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ABUSE & NEGLECT: (PLEASE SIGN BELOW) If it is our judgment, at any time while you are completing classes, that current abuse and/or neglect of a child is occuring, we will be required to report this to your state's Department of Human Services and to the police. This includes reporting violent incidents that occur in the presence of children. We will make an effort to contact you to let you know we have made this report and we will encourage you to make the report yourself. 2. If you threaten to harm or kill another person during your enrollment in classes, we are Obligated to warn that person of the threat as well as to notify the police. In such cases, if we are subpoenaed by the court to testify, we may be required to violate your confidentiality. 3. If you commit a criminal offence while you are enrolled in classes, we will report such information to the police. We will also encourage you to make a report yourself. In such cases, if we are subpoenaed by the court to testify, we may be required to violate your confidentiality.4. If at any time during your enrollment in classes you are a danger to yourself or to another person, we will share that opinion with you. We will also inform the other person and the police. With regard to reporting known or suspected child abuse or neglect, state law mandates that abuse or neglect to Child Protective Services. Should such you become involved with such child abuse or neglect, you will be given the chance to report the abuse or neglect yourself; however, if you refuse to report it, Transformations BIP LLC is Obligated to report their suspicions. We Will promise confidentiality with respect to the general public; the news media; anyone else not covered in the exceptions stated above. Within these limitations, we will take your privacy and confidentiality very seriously in order to protect your privacy, the privacy of your current or past partners, and the privacy of any children who are involved. Please Be Advised: Any reasonable knowledge or suspicion of illegal activities or bodily harm, or a threats to a victim, her/his property, or any belief that child abujse or neglect is present or has occurred, will be reported to the appropriate person(s) or authorities.Write in the blank below "I understand" If by any means, accidental or as a part of classes you become privy to another of our class participant's information, etc. you agree not to discuss or otherwise share this information with anyone else. TYPE YOUR NAME below in agreement:
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CLASS COMPLETION POLICY: (PLEASE SIGN BELOW) By electronic signing below I acknowledge I understand: This class is solely intended for the enrolled class particant and I understand that I MAY NOT RECEIVE ASSISTANCE FROM ANYONE ELSE TO COMPLETE MY CLASSES AND DOING SO WILL VIOLATE Class Policies. I understand I may not COPY NOR PRINT any class material at any time. I understand doing either of the above items will violate the terms of my contract and will result in immediate termination from the classes. I have read, understand and agree to this Policy and agree to abide by its contents. In accordance with the Uniform Electronic Transactions Act (15 US Code, Section 7001) I agree that typing my name has the same force and effect as having signed my signature. I also understand I can print a copy of this form. TYPE YOUR NAME below to acknowledge you understand:
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If you have committed domestic violence, what is the Victim's name, address and phone number? (List whatever information you have, do not contact victim to gather this information) What is your relationship to the victim? Do you still have contact with the victim or live with the victim? How long have you known the victim?
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What is your attorney or public defenders name, phone number and email address? (If you don't have one write none)
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Are you on probation/parole? Describe the conditions of your probation/parole (if any).
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Who is your probation/parole officer and what is their email address and phone number? (Write none if you are not on probation/parole)
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Have you previously completed domestic violence classes? If so when and how many sessions did you complete?
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Describe the worst violence you have committed, who it was toward and when it was.
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List any you have done in the past. Pushed, punched, slapped, spit on, kicked, pulled hair, tore clothing, throwing or breaking things, choking, restrained., other physical acts. These classes are for offenders, not victims of domestic violence.
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These are some Emotional Abuse behaviors others have used. LIST ALL THAT APPLY to you: Put your partner down, called names, humiliated them, made them feel guilty, interrupted their sleeping or eating, acted jealous Screamed, smashed things, displayed weapons, made them afraid with looks or gestures . Threatened to harm them, threatened their family and friends, made them do something illegal, tried to get them to drop charges.
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These are some Denying & Blaming behaviors others have used. LIST ALL THAT APPLY to you: Made light of the abuse, said the abuse was their fault, said it didn’t happen. Told the children they are not a good parent, used children to deliver messages, threatened to take the children away, used visitation to harass your partner or write NONE
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These are some 'Macho' behaviors others have used. LIST ANY YOU HAVE DONE: Treated your partner like a servant, acted like the Master of the Castle, Boss them around, did not share in chores, expected sex on demand, made household rules w/out their input. Keeping the checkbook, made them ask for money, withheld family income, not paid child support, prevented them from working, made major financial decisions
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COMMUNICATION POLICY: (PLEASE SIGN BELOW) I understand that any reasonable knowledge or suspicion of illegal activity or bodily harm,or a threat of such, to the victim, their property, or to third persons, or any attempt, threat, or gesture to commit suicide, or any belief that child abuseor neglect is present will be reported to the appropriate person/authorities.I have read this agreement and fully understand all of the requirements. I understand Transformations BIP LLC may have regular communication including written, verbal, fax, mail, and email communicationwith the Judge, Court Personnel, Attorneys, District Attorneys, Public Defenders related to my case so long as my classes are active and in follow-up for 6 months after my last class has been completed. I further understand that electronic mail is not confidential and can be intercepted and read by other people thus only my compliance or non-compliance shall be communicated via email with court personnel. TYPE YOUR NAME below in agreement
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LIST ALL THAT APPLY: your partner tried to get outside help, went to a shelter, you hurt them while pregnant, they got medical help after the violence, you have threatened to kill them, you have used a weapon or threatened to, you have threatened to commit suicide, forced them to have sex, pressured them to watch pornography
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(SIGN BELOW) Type your NAME below to acknowledge you understand: No credit, completion and NO REFUND will be given If the Class is Completed by Anyone Other Than You or if you are assisted by an outside party or electronic means. When you enroll in the class you are stating under penalty of perjury that you, and not another person, will study the material in its entirety and complete lesson /quizzes with no 3rd party assistance. To acknowledge you agree to the above paragraph TYPE YOUR NAME here:
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(SIGN BELOW) I understand if it is determined I am being disruptive or don't appear to be progressing in the classes I may be referred to complete my classes at an alternative agency. Reasons for involuntary termination shall include, but are not limited to: recurrence of violence; arrest; failure to submit classes in a timely manner; failure to actively participate; violation of any rules or violation of the class policies. TYPE YOUR NAME below in agreement:
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Marital status: Single/Divorced/Separated?
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PAYMENT POLICY: (PLEASE SIGN BELOW) By typing my name I agree if I ever have an error or dispute regarding my payments, I will contact Transformations directly via email to allow the error to be resolved prior to contacting my credit card company. I also authorize Transformations BIP LLC to address disputes with Stripe regaring my account. I understand there is a 60 day money back guarantee if for any reason the classes do not meet the requirements for my situation, I understand I will have 60 days from the date of my initial enrollment to request a refund and all fees paid in the first 60 days will be fully refunded. I understantd it is my responsibility to ensure online DV classes will be accepted in my specific situation. Please TYPE YOUR NAME in agreement of the payment policy:
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How many criminal convictions have you had? (Do not include traffic violations) How many were Felony convictions? Number of times on Probation or parole? How many times was it revoked?
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Do you have a current criminal charge (for Example: 'Felony Domestic Assault and battery in the presence of a minor)
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Number of domestic violence related arrests? alcohol related? drug related? Total number of times arrested? sentenced to jail? sentenced to Prison?
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I agree to refrain from abusive behavior towards my partner or victim while participating in the classes. I agree to remove all firearms from my home and vehicles by the time I begin classes if required by my probation/parole. The Firearms will remain outside my home or vehicles until I have completed the classes. I will abide by the federal and state laws in my area regarding firearms. TYPE YOUR NAME below in agreement:
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Did you ever experience child abuse or witness domestic violence growing up? Describe your family environment growing up: (Who raised you,number of siblings, traumatic events, the environment, etc)
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Describe your current alcohol use (How often do you drink, what kind, and how much. Please be honest and specific. Describe your current drug use. (How often, what kind, and how much.)
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There have been times when I have gotten angry and thrown things or broken items: True/False
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In the past I have used a weapon or threatened to use a weapon against my past or present partner: True/False
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In the past I have threaten to kill my partner or partner's family members: True/False
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In the past I have choked or attempted to choke my past or present partner: True/False
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In the past I have followed or spied on my partner: True/False
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One or more of my partner's have said I am a jealous person: True/False
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My current partner has a child that is not mine: True/False
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My current partner is pregnant: True/False
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I usually control the finances in our house: True/False
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I agree that if I currently have a protective order/restraning order against me or if I have one placed on me, I agree to follow every condition of the order. I agree to refrain from all violent behavior, including harming others, threats, throwing things, punching holes in walls, breaking things, and all other violent acts. The victim and past/present partner may receive information about your class enrollment, progress, discharge, and any threats made toward them while attending classes. I understand they will contacted if we believe there is an imminent threat or danger to the partner or victim. TYPE YOUR NAME to acknowledge your understanding and agreement:
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Once my enrollment is successfully received I will receive a Proof of Enrollment Letter by email. In addition I understand email may or may not be a secure form of communication and I give my consent to receive email communication from Transformations BIP LLC. I understand I MAY REQUEST STATUS UPDATES for court/probation by emailing a request. I understand I need to plan ahead and ALLOW 48 HOURS for the request to be processed. Requests need to be in writing by EMAILING US YOUR REQUEST for a Status Update Letter. Please Write "I Understand I need to allow 48 hours to receive a Status Update Letter."
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YOU ARE REQUIRED TO MAKE WEEKLY CONTACT. You may complete your class anytime day or night but YOU MUST SUBMIT YOUR CLASS BY SUNDAY NIGHT or Email Us why the quiz will be late and WHEN it will be submitted. If you submit your quiz as required you Do Not need to email us. Please write out this sentence in the line below "I Understand I am Required to Make Weekly Contact in Order to Remain Compliant with the classes."
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PLEASE SIGN YOUR NAME BELOW: Our classes are educational in nature and are not therapy, counseling, or mental health services. By signing below you acknowledge you understand these classes are nationwide and not certified in any particular state. If you are needed "state-certified" classes, please call the court house in your local area. Notice of Information Practices and Privacy Statement How We Collect Information About You: As part of your enrollment in classes, Transformations BIP LLC and its employees and volunteers collect data through a variety of means including but not necessarily limited to letters, phone calls, emails, voicemails, and from the submission of applications that are either required by law or necessary to process applications or other requests for assistance through our organization. What We Do Not Do With Your Information: Information about your financial situation and conditions and care that you provide to us in writing, via email, on the phone (including information left on voicemails), contained in or attached to applications, or directly or indirectly given to us, is held in strictest confidence. We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about applicants or class participants who apply for or actually receive our services that are considered confidential, is restricted by law, or has been specifically restricted by a class participant in a signed consent form. How We Do Use Your Information: Information is only used as is reasonably necessary to process your application or to provide you with services which may require communication between IHSN and health care providers, medical product or service providers, pharmacies, insurance companies, and other providers necessary to: verify your information is accurate;or to obtain or purchase any type of medical supplies, devices, medications, insurance,If you apply or attempt to apply to receive assistance through us and provide information with the intent or purpose of fraud or that results in either an actual crime of fraud for any reason including willful or un-willful acts of negligence whether intended or not, or in any way demonstrates or indicates attempted fraud, your non-medical information can be given to legal authorities including police, investigators, courts, and/or attorneys or other legal professionals, as well as any other information as permitted by law. We do use some programs that may or may not capture traffic date through our site. Limited Right to Use Non-Identifying Personal Information From Biographies, Letters, Notes, and Other Sources: Any pictures, stories, letters, biographies, correspondence, or thank you notes sent to us become the exclusive property of TBL. We reserve the right to use non-identifying information about our class participants (those who receive services or goods from or through us) for fundraising and promotional purposes that are directly related to our mission. Participants will not be compensated for use of this information and no identifying information (photos, addresses, phone numbers, contact information, last names or uniquely identifiable names) will be used without express advance permission. You may specifically request that NO information be used whatsoever for promotional purposes, but you must identify any requested restrictions in writing. We respect your right to privacy and assure you no identifying information or photos that you send to us will ever be publicly used without your direct or indirect consent. TYPE YOUR NAME below in acknowledgement of your understanding of the above paragraph:
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Do you have a Case Worker / Family Case Worker that you would like to add to the above statements for us to release your class completion/compliance updates to? IF YES TYPE THE NAME OF THE AGENCY & CONTACT INFO IN THE LINE BELOW. If you do not have a case worker just write NONE.
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What is your gender?
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Please note we cannot process your enrollment if any of the following apply: only 1 person per case may enroll (the first one to complete the enrollment forms), your case involves children/DHS/CPS, your enrollment forms are missing information/are incomplete/contain explicit language, or you are the victim in the case. Please type your name below to confirm you understand.
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What is your date of birth:
Email: CAREFULLY type your email
example@example.com
You are Done! PLEASE DO NOT RE-SUBMIT YOUR ENROLLMENT FORMS once you hit send. You do not need to call, Just WATCH YOUR EMAIL the next 48 hours for your Proof of Enrollment and & instructions to complete your first class. IF YOU DO NOT RECEIVE AN EMAIL from us within 48hrs it means your Email Address was Typed Incorrectly below. Please CAREFULLY type your email ---------DOUBLE CHECK YOUR EMAIL. IF YOU DO NOT GET AN EMAIL FROM US, IT MEANS YOUR EMAIL ADDRESS CAME BACK AS INVALID/FULL:
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Submit
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