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Phone (H)___________________ (W)__________________

S.S.# (for payment plan)________________________

Address_____________________________________________________ Apt:______

City____________________

State______ Zip____________ Email Address____________________________

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
Check either accelerated or weekend classes, plus advanced classes
( ) Weekend Format (Minimum For Certification As A Hypnotherapist, 250 hours)
Start Date ______________
___ Fundamentals of Hypnotism/Hypnotist Training
___ Master Hypnotist Training
___ Hypnotherapist Training

( ) Accelerated Format (Minimum For Certification As A Hypnotherapist, 250 hours)
Start Date ____________
___ Fundamentals of Hypnotism
___ Hypnotist Training
___ Master Hypnotist Training
___ Hypnotherapist Training

( ) Advanced Classes For Certification As A Clinical Hypnotherapist
Start Date _____________
___ Prenatal Regression & Adv. Transforming Therapy
___ Healing and Pain Control

( ) Elective
___ Past Life Therapy

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%
Additional expenses: up to $225 for text books and $175 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 Commission on Higher Education, 5301 Central NE, Suite 1500, Albuquerque, NM, 87108.
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. In connection with my application with the school, I understand that a consumer report which may contain public records information is being requested. This report may include the following types of information: names and dates of previous employers, credit information, etc. I further understand that such report may contain public record information concerning my credit, bankruptcy proceedings, etc. from federal, state and other agencies which maintain such records. I authorize without reservation, any party or agency or agency contacted to furnish the above mentioned information. 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 6.6875%) 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 __________________

Signature of applicant __________________________________ Date_______________

Signature of school official _________________________________Date____________

Personal Background
Please briefly answer the questions within the space provided below

Why do you want to learn hypnotherapy?

Why do you feel you would make a good hypnotherapist?

Tell us about your personal growth experiences.

Have you ever been in therapy?
yes      no

If yes, please describe your experience to whatever depth you feel comfortable.

Do you know of any physical or mental condition(s) that would disqualify you from participating in that kind of training course?
yes      no

If yes, please describe.

How did you hear about us?