Third-Party Authorization – Hoffman Institute

This form is the authorization for expenses to be paid by a third party on behalf of a Participant in a Hoffman Institute program. Please provide all the information requested below, including your signature. Upon completion, click "Submit" at the end of the form.

If you prefer to fill out this form by hand, click here to download a printable pdf. Once completed, fax it back to our office at 415-485-5539.

This form is the authorization for expenses to be paid by a third party on behalf of a Participant in a Hoffman Institute program. Please provide all the information requested below, including your signature. Upon completion, click "Submit" at the end of the form.

If you prefer to fill out this form by hand, click here to download a printable pdf. Once completed, fax it back to our office at 415-485-5539.

Your Name*

First Last

Company (if applicable)

Your Email*

Your Phone*

Phone Type*

Participant Information

Name of participant you are paying for:*

First Last

That participant's email address:*

Your relationship to that participant

Program Date*

(leave blank if unknown)Please select a program date in this drop-down menu to show charges.

Program Location*

United States
Canada

Approved Charges

All prices are in Canadian Dollars (CAD) and include sales tax (business number 74026 0419 RT001).

Please note: Your agreement to pay for any of the following items DOES NOT RESERVE those items. Participant must register themselves and must call in advance to request all lodging options.

I agree to pay this specific amount only:*

(Please see below for itemized tuition and program-related costs that can be selected instead of indicating a specific amount.)

I agree to pay these Tuition costs:

Tuition Deposit (due at time of Participant registration)*

Yes
No

Tuition Balance (less any scholarships, discounts or promotions; due 10 days prior to start of program)*

Yes
No

Full Tuition (less any scholarships, discounts or promotions; due at time of Participant registration)*

Yes
No

I agree to pay for these additional optional program-related costs:

ROOM WITH PRIVATE BATH - add $500 USD per program (Participant must call to reserve)*

NOTE: Tuition is based on single occupancy rooms. Bathrooms are shared, and lock for private use. However, there are a limited number of rooms with a private bathroom, not shared with another student.

Yes
No

ROOM WITH PRIVATE SHOWER - add $100 CAD per program (Participant must call to reserve)*

NOTE: All rooms are single occupancy rooms and have half baths (toilet and sink). However, there are a limited number of rooms with a private shower, not shared with another student.

Yes
No

ROOM WITH PRIVATE SHOWER - add $300 CAD per program (Participant must call to reserve)*

NOTE: All rooms are single occupancy rooms and have half baths (toilet and sink). However, there are a limited number of rooms with a private shower, not shared with another student.

Yes
No

ROOM WITH PRIVATE BATH - add $250 per program (Participant must call to reserve)*

NOTE: Tuition is based on single occupancy rooms. Bathrooms are shared, and lock for private use. However, there are a limited number of rooms with a private bathroom, not shared with another student.

Yes
No

LODGING THE NIGHT BEFORE PROGRAM*

(not included in program tuition)
California programs only: $150 payment due at time of stay (Participant must call to reserve)
For Connecticut programs call directly to make payment arrangements: (860) 322-5770.

Yes
No

SHUTTLE THE NIGHT BEFORE PROGRAM*

If arriving by air, round-trip airport Shuttle is $160 (not included in program tuition). No additional cost for lodging if arriving by car Friday night. (Participant must call to reserve)

Yes
No

LODGING THE NIGHT BEFORE PROGRAM*

(not included in program tuition)
Payment due at time of stay. $200 if arriving by air (includes shuttle). $100 if arriving by car. (Participant must call to reserve)

Yes
No

Store merchandise purchases, due at time of purchase*

Yes
No

Payment Options

I will pay by:

Credit Card with last 4 digits ____________ (If you have not already provided full credit card information please call the office at 415-485-5220.)
Check (mail to: Hoffman Institute, 1299 Fourth St, Suite 600, San Rafael, CA 94901 - note: checks are held until student registers by phone)(mail to: Hoffman Institute, Suite 337, 4-168 Barton Street, Stoney Creek, ON, L8E4V6 - note: checks are held until student registers by phone)

I will pay by:*

Credit Card
Check (mail to Hoffman Institute - note: checks are held until student registers by phone)

American Express and Discover cards are not accepted for Canada Programs. If you would like to pay with these, please contact enrollment@hoffmaninstitute.org

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mail checks to:

Hoffman Institute
1299 Fourth St, Suite 600
San Rafael, CA 94901

Mail checks to:

Hoffman Institute
Suite 337, 4-168 Barton Rd
Stoney Creek, ON L8E 4V6

Cancellation and Refund Policy

I understand that a deposit is required for enrollment in the Process. It applies to a specific Process date and to the above named Participant and is non-refundable and is not transferable to a different Process date or Participant. The balance of the tuition and additional single room lodging options during course are due 10 days prior to the Process start date. If the Participant withdraws or requests to transfer during the 10 days prior to the start date of their Process, the deposit, room and board costs are forfeit and the remaining balance of monies can be transferred or refunded at my request. If the Participant withdraws or requests to transfer after the start of the first class session, all monies are forfeit.

I further understand that the Process may be cancelled at any time at the Hoffman Institute Foundation’s (the Institute) sole discretion. If the Process is cancelled by the Institute, the Participant’s registration may be transferred in full to a different Process date or Participant, or the payer may be refunded all monies paid to the Institute. I further understand that the Participant’s enrollment in the Process may be cancelled or terminated at any time at the Institute’s sole discretion. If the Participant is dismissed for breach of this agreement or their Enrollment Agreement with the Institute during the 10 days prior to the start date of their Process, the deposit, room and board costs are forfeit. If the Participant is dismissed by the Institute after the start of the first class session, all monies are forfeit. By electronically signing this agreement (in the box below), I acknowledge that this Agreement contains the entire understanding between myself and the Institute and may not be modified except by a written instrument agreed to by both parties.

I understand that a $400 deposit is required for enrollment in the Q2. It applies to a specific Q2 date and to the above named Participant and is non-refundable and is not transferable to a different Q2 date or Participant. The balance of the tuition and additional single room lodging options during course are due 14 days prior to the Q2 start date. If the Participant withdraws or requests to transfer during the 14 days prior to the start date of their Q2, the deposit, room and board costs are forfeit and the remaining balance of monies can be transferred or refunded at my request. If the Participant withdraws or requests to transfer after the start of the first class session, all monies are forfeit.

I further understand that the Q2 may be cancelled at any time at the Hoffman Institute Foundation’s (the Institute) sole discretion. If the Q2 is cancelled by the Institute, the Participant’s registration may be transferred in full to a different Q2 date or Participant, or the payer may be refunded all monies paid to the Institute. I further understand that the Participant’s enrollment in the Q2 may be cancelled or terminated at any time at the Institute’s sole discretion. If the Participant is dismissed for breach of this agreement or their Enrollment Agreement with the Institute during the 14 days prior to the start date of their Q2, the deposit, room and board costs are forfeit. If the Participant is dismissed by the Institute after the start of the first class session, all monies are forfeit. By electronically signing this agreement (in the box below), I acknowledge that this Agreement contains the entire understanding between myself and the Institute and may not be modified except by a written instrument agreed to by both parties.

I understand that the non-refundable full tuition payment is required for enrollment in this virtual program and applies to and to the above-named Participant and specific program date. The payment is not transferable to another person or different program date.

If the Participant withdraws after the Friday two weeks prior to the program, Participant may:

1. transfer to another date, which would require an additional $100 transfer fee, or

2. I may request a tuition refund (minus an administration fee of $100).

This virtual program may be cancelled at any time at the Institute’s sole discretion. If the program is cancelled, the applicant may transfer their registration to another virtual program of the same type with no additional charge, or receive a full refund of all monies paid to the Institute.

The applicant’s participation in the program may be cancelled or terminated at any time at the Institute’s sole discretion. If the applicant withdraws from the program after the start of the first session, or if the applicant is dismissed for breaching this agreement or breaking Institute rules, no part of the program fee shall be refunded.

I understand that the $400 deposit is required for enrollment in this virtual program and applies to a specific course date and to the above named Participant and is non-refundable and is not transferable to a different program date or Participant.

The tuition balance is due 8 days prior to the start of the program. If the participant withdraws after the balance due date but before the program start date, the deposit is forfeit and the remaining balance of monies (minus an administration fee of $50) can be transferred or refunded at my request. If the participant transfers to a different program date during this time period, an additional $400 deposit will be required. If the Participant withdraws or requests to transfer after the start of the first class session, all monies are forfeit.

This virtual program may be cancelled at any time at the Institute’s sole discretion. If the program is cancelled, the participant may transfer their registration to another virtual program of the same type or you will receive a full refund of all monies paid to the Institute.

The applicant’s participation in the program may be cancelled or terminated at any time at the Institute’s sole discretion. If the applicant withdraws from the program after the start of the first class session, or if the applicant is dismissed for breaching this agreement or breaking Institute rules, no part of the program fee shall be refunded.

By electronically signing this agreement (in the box below), I acknowledge that this Agreement contains the entire understanding between myself and the Institute and may not be modified except by a written instrument agreed to by both parties.

Signature*

To sign your name, place your cursor over the signature box, then hold down your mouse key to utilize the pen, or use your finger on your track pad or device screen. You may want to rotate your device horizontally.

Date

Product Name