Name____________________________________________________
Email address________________________
Phone (H)___________________ (W)__________________ (Cell)_______________________
Address_____________________________________________________ Apt:______
City____________________ State______ Zip____________ Country ________________
Date of birth_____________
Birth place___________________
Present occupation__________________________________
Prior Education (A minimum of a high school diploma or GED required)
High School Attended__________________________________________________
GED date of completion__________________
College/University_____________________________________________
Level Completed__________________
Degree awarded/major___________________________________________________________
Previous hypnotherapy training (not a prerequisite) _____________________________________________________
Total classroom hours_____
Have you ever been convicted of a felony or morals charges? ___yes ___no.
If yes, please explain on and 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
Make a check-mark below and write in the beginning date, to indicate which classes you will be attending, including advanced classes:
( ) Accelerated Format (Minimum For Certification As A Hypnotherapist, 250 hours)
Start Date ____________
___ Fundamentals of Therapeutic Hypnosis
___ Master Hypnotist Training
___ Hypnotherapist Training
( ) Advanced Classes For Certification As A Clinical Hypnotherapist
Start Date _____________
___ Healing and Pain Control
( ) Electives
Start Date ____________
___ Natal, Interlife & Past Life Therapy
Start Date ____________
___ Creative NLP for Hypnotherapists
Refund policy: If a student drops “the course” (inclusive of all modules or levels checked above on page 1) and written notice is given to the Director in person by the student, or by certified mail, refundable tuition will be returned within 30 days of official notice according to pro rata attendance schedule following. “Attendance time” is the time between the start date of “the course” and the date on which enrollment is officially canceled, (whether or not 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 that you have read the refund policy___________
Additional expenses: up to $235 for required text books and $225-$325 (depending on level of certification) for certification and testing.
Student complaint policy: The Director will first address all complaints and will do their best to find satisfactory solutions. If this is not satisfactory, the student may choose to file a verified complaint to the following address.
New Mexico Higher Education Department, 2048 Galisteo, Santa Fe, NM, 87505-2100.
Dismissal policy: At the discretion of the Director, a student may be dismissed from school for an intoxicated or drugged appearing state of behavior, possession of illegal substances, alcohol, or weapons on school premises, behavior creating a safety hazard to other persons at school, disrespectful behavior to those at school, or not maintaining an acceptable academic or practical skill level as determined by the Director, or any other reason stated or determined inappropriate action or behavior by a student of the Academy of Alternative Therapies/Hypnotherapy Academy of America, by the Director.
Agreement: I have read the current catalog, refund, complaint, and dismissal policies and understand my obligations as well as the school’s. I understand 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 information given on this form is to the best of my knowledge correct.
To apply for your seat in the class, please enclose a minimum $300 deposit, plus any additional tuition payment and tax. (Current State Tax rate is 8.0625%) Your deposit is applied to your tuition, $100 is non-refundable.
Amount of payment __________________ Method of payment:___________________
Please circle Am.Ex. MasterCard Visa Discover
Credit Card # ___________________________________________
Exp. Date __________________ 3-digit verification code on back of card __________
Signature of applicant __________________________________ Date_______________
Signature of school official _________________________________Date____________
