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________________________________________ 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 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 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 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 $250 for required text books and $285 for optional certification.
Recommended but not required: 2-4 private sessions with staff hypnotherapists (student discount applies)

Student complaint policy: The Directors 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 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 creating 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 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 correct to the best of my knowledge.

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 7%) Your deposit is applied to your tuition, $100 is non-refundable.

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 _________