Enrollment Application

Hypnotherapy Academy of America

Enrollment Application

Last Name: ________________________ First Name: _______________________ Middle: _________

Phone (Home):___________________ (Work):____________________ (Cell):_____________________

Address:_____________________________________________________ Apt:________

City:____________________ State:______ Zip:____________ Country: ________________

Email address:_________________________________________________________

Date of birth:_______________  Birth place:_________________________________

Present occupation:__________________________________________

Prior Education (A minimum of a high school diploma or GED required)

High School Attended:______________________________________ Date of completion:_____________


Level Completed:__________________

Degree awarded/major:___________________________________________________________

Previous hypnotherapy training (not a prerequisite): __________________________________________________

Total hours:_________

Have you ever been convicted of a felony or morals charges?: Yes:____      No:____

If yes, please explain on an attached sheet of paper:

Note: All students are required to practice and experience hypnotherapy during class.
All classes may be taken individually or as a package.
See Course Catalog for start dates and current tuition.
Make a check-mark inside the parentheses below and write in the beginning date, to indicate which classes you will be attending, including electives:

( ) Hypnotherapist Training 300 Hours Required
Start Date: ____________
___ Hypnotherapy Training – Module 1, 100 Hours
___ Hypnotherapy Training – Module 2, 100 Hours
___ Hypnotherapy Training – Module 3, 100 Hours

( ) Clinical Hypnotherapist Training 400 Hours Required
Start Date: _____________
___ Healing and Pain Control – Module 4, 100 Hours

( ) Elective
Start Date: ____________
___ Natal Regression, Interlife Exploration & Past Life Therapy – Module 5, 100 Hours

Refund policy: If a student drops “the course” (inclusive of all modules or levels checked above on page 1, regardless of being taken consecutively or not) and written notice is given to the school, refundable tuition will be returned within 30 days of official notice according to pro rata attendance schedule below. “Attendance time” is the time between the start date of “the course” and the date on which enrollment is officially canceled, (whether or not the student attends class).

Attendance time/ Portion of tuition that school retains (plus the $100 deposit.)

From time of deposit to first day =0%
up to 10% =10%
11% to 25% =50%
26% to 50% =75%
50% or thereafter 100%

Student, please initial to confirm that you have read the refund policy:___________

Additional expenses: up to $275.00 for required text books and $300.00 for optional certification.

Recommended but not required: 2-4 private sessions with staff hypnotherapists (student discount applies)

Student complaint policy: Per the New Mexico Higher Education Department, student or other parties with complaints or grievances are to first seek to resolve their complaint with the educational institution.  No adverse action will be taken against the complainant for registering a complaint.  An impartial representative of the institution, not directly involved in the area of the complaint, will serve as a representative of the institution to hear and attempt to resolve the complaint.  The institution will investigate the complaint and respond within 30 days.  If the findings of the investigation is not satisfactory, the complainant may choose to file a complaint with the New Mexico Higher Education Department, Private Post Secondary Schools Division at 2044 Galisteo Street, Suite 4, Santa Fe, NM, 87505.

Dismissal policy: At the discretion of the Directors, a student may be dismissed from the course, without refund of tuition, for intoxicated or drugged appearing behavior, possession of illegal appearing substances, alcohol, or weapons on school premises, behavior that creates a safety hazard to other persons at school, disrespectful behavior to those at school, disrupting the educational environment, not maintaining an acceptable academic or practical skill level, or any other action determined inappropriate.  The student is always responsible for the payment of their tuition.  If the student loses a sponsorship or funding from a third party, the student must pay the tuition or they will be dismissed for non-payment.

Agreement: I have read the current catalog, refund, complaint, and dismissal policies and understand my obligations as well as the school’s.  I understand that the instruction received does not imply education in any medical field and that I will not use hypnosis for medical purposes, including psychiatric, for which I am not licensed, unless working under the supervision of a person licensed for that purpose and as prescribed by law.  I further understand that these classes are not for the purpose of diagnosing, or the treatment of, any physical or mental ailment.  I certify that all the information I give on this form is correct to the best of my knowledge.
Please Note: Photo identification is required on the first day of class.

To apply for your seat in the class, please enclose a minimum $500.00 deposit, plus any additional tuition payment and tax.  (Current State Tax rate is 7.5%) Your deposit is applied to your tuition, $100.00 is non-refundable.

Signature of applicant: _____________________________________ Date: ______________

Signature of school official: __________________________________ Date:  ______________


Amount of payment: ________________________    Method of payment:___________________

Please circle:      Am.Ex.      MasterCard      Visa       Discover

Credit Card #: ______________________________________________ Exp. Date: __________________

Signature for credit card: __________________________________ Date:_____________  V Code: _________