Note: an interview with Instructor Mary Elizabeth Raines is required before acceptance into the hypnosis certification program. Please print and fill out the below form only if you have already completed your interview. Mail completed form, together with your deposit, to the address listed at the bottom of the page.

REGISTRATION FORM
ACADEMY FOR PROFESSIONAL HYPNOSIS TRAINING

 

FULL NAME (Please Print)________________________________________________________

NAME BY WHICH YOU WOULD LIKE TO BE CALLED___________________________________________

MAILING ADDRESS ___________________________________________________________

TELEPHONE (HOME)__________________(WORK)____________________(CELL)_____________

E-MAIL (Will be used only for school communications)_________________________________________

DATE OF BIRTH ______________________________


CURRENT PROFESSION_________________________________________________________

EDUCATION OR OTHER TRAINING YOU HAVE HAD WHICH MIGHT BE PERTINENT TO HYPNOSIS:

______________________________________________________________________

BRIEFLY DESCRIBE YOUR INTEREST IN STUDYING HYPNOSIS:

______________________________________________________________________

______________________________________________________________________

ANY PERSONAL CONDITIONS/CIRCUMSTANCES/ALLERGIES/ANYTHING ELSE OF WHICH YOU WOULD LIKE US TO BE AWARE:

_______________________________________________________________________

 

I HAVE READ AND AGREE TO THE FOLLOWING:

To receive certification, students are required to attend the entire course, be reasonably punctual, make up for any time lost due to unavoidable tardiness or excused illness, participate in all class exercises, and satisfactorily complete the course requirements, as well as the post-graduate requirements.

____________________________________________________________

  Name Date

DEPOSIT ENCLOSED IN THE AMOUNT OF: _______________($400 minimum; balance due on the first day of class)

 

Thank you! We look forward to meeting you soon!

Please make out check to M. E. Raines and mail together with this form to:

Academy for Professional Hypnosis Training
Att'n: M. E. Raines
E5664 Waukaunaka St.
Weyauwega, WI 54983

Refund policies: a minimum deposit of $400 is required to enroll and to be eligible for early enrollment discounts. $375 of this amount is refundable up until six weeks before the beginning of class. From four to six weeks, $200 of this amount is refundable. After this time, the deposit becomes non-refundable. Once class begins, tuition is non-refundable. A portion of the amount may be applied to another Academy for Professional Hypnosis Training program if the cancellation was due to a verifiable medical or family emergency (documentation required), or upon consultation with Ms. Raines.