Note: an interview with Instructor Mary Elizabeth Raines is required before acceptance into the Guided Imagery 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.


Academy for Professional Hypnosis Training

GUIDED IMAGERY TRAINING
REGISTRATION FORM

 

FULL NAME (Please Print)___________________________________________________________________________________________________________________________________________

 

NAME BY WHICH YOU WOULD LIKE TO BE CALLED_______________________________________________________________________________________________________________________

 
MAILING ADDRESS ______________________________________________________________________________________________________________________________________________

 
_____________________________________________________________________________________________________________________________________________________________

 
______________________________________________________________________________________________________________________________________________________________

TELEPHONE (HOME)___________________________(WORK)______________________________(CELL)___________________________

 

E-MAIL

_______________________________________________________________________________________________________________________________________________________________

 

DATE OF BIRTH ______________________________________________________________________________

 

CURRENT PROFESSION________________________________________________________________________________________________________________________________________________________

 

EDUCATION OR OTHER TRAINING YOU HAVE HAD WHICH MIGHT BE PERTINENT TO GUIDED IMAGERY COURSE:

 

____________________________________________________________________________________________________________________________________________________________________________

 

BRIEFLY DESCRIBE YOUR INTEREST IN STUDYING TO BECOME A GUIDED IMAGERY COUNSELOR:

 

 

 

_____________________________________________________________________________________________________________________________________________________________________________

 
PLEASE CHECK ALL THAT APPLY:
 

  • I would like to be connected with another student(s) for sharing a room
    (All room reservations are the responsibility of the student)
  • I would be interested in being on a list to carpool to/from airport
  • I would be interested in being on a list to carpool to/from class
     

PLEASE SHARE ANY PERSONAL CONDITIONS INCLUDING MEDICAL HISTORY/SERIOUS ALLERGIES/OTHER CIRCUMSTANCES OF WHICH WE NEED TO BE AWARE:

________________________________________________________________________________________________________________________________

NAME, CURRENT PHONE NO. & EMAIL OF EMERGENCY CONTACT___________________________________________________________________________________________________________________________________________________________________

ELIGIBILITY REQUIREMENTS: To be eligible for certification, students are required to attend al lsessions, including evening sessions, without excessive tardiness or early departure; to participate in all exercises; and to demonstrate by the end of the course an ability to conduct a guided imagery session.

I have read, understand and agree to all terms and conditions (click to go to terms and conditions page):
 

 

Signed__________________________________________________________________Date______________________________

PERSONAL RESPONSIBILITY CLAUSE: Each individual is responsible for her/his own emotional, physical and mental wellbeing. By signing this contract:
1. You agree to take personal responsibility for yourself.
2. You agree that you have never been treated or hospitalized for psychiatric reasons or for any mental illness.
3. You agree that you, your family and your heirs will hold the Academy for Professional Hypnosis Training, Laughing Cherub Hypnosis and/or Mary Elizabeth Raines harmless and not liable for any perceived or actual emotional, physical or mental injury or loss.

______________

 

DEPOSIT ENCLOSED IN THE AMOUNT OF: _______________($225.00 US dollars minimum)

Registration and deposit must be postmarked by the above date to qualify for any potential discounts. Sorry, but there can be no exceptions under any circumstances. See below for discount and refund policy.

Call us if you have extra deductions for bringing along a friend: (928)282-2640

  • General Tuition: $460.00
  • Tuition Discount of $75.00 for those who enroll by January 23, 2016: $385.00
  • Bring-a-Friend Discount: $1apiece, in addition to above discounts.
     

 

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

M. E. Raines
Academy for Professional Hypnosis Training
PO Box 1059
Sedona, AZ 86339

Thank you, friend! We look forward to meeting you soon!

 

Note to students: Your registration is your commitment to take the class. Our commitment to you is that we will hold the class as scheduled, barring circumstances called "acts of God." The below refund policy is in place since our commitment entails making a substantial, nonrefundable deposit for multiple items as supplies, catering,office work, airfare, classroom space rental lodging.

DISCOUNT AND REFUND POLICY

Tuition discounts, if any, are only applicable if deposit has been postmarked by due date and balance is paid before or on the first day of class. Discount for bringing a friend is only applicable if both parties enroll in and pay for entire course in a timely fashion. In the event of any delay in payment, all discounts will be null and void.

Refund policies: a minimum deposit of $225 is required to enroll. The deposit amount, minus a $40 bookkeeping fee, is completely refundable up until four weeks before the beginning of class. From four weeks to one week before the start of class, refunds will be given for any amount in excess of $225; the remainder is non-refundable, however $185 may be applied to another Academy for Professional Hypnosis Training program if the cancellation is due to a verifiable medical or family emergency (legal documentation required; no exceptions). Starting one week before the opening of class and continuing after class begins, there will be no refunds.


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