Application for Admission 265-Hour I-ACT Professional Certification Course
Participant Registration Form
Name:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Phone Number
*
Emergency Contact
Please enter a valid phone number.
Format: (000) 000-0000.
Please list the high school, college, healing arts and/or health professional institutionsyou have attended and certifications and/or degrees awarded. Please submit copies of school transcripts, GED, degrees, licenses, or certifications.Please state name if different on school record:
File Upload - High Schoo Diploma and others
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File Upload - Prove Of CPR Certification
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Why do you want to become an I-ACT Colon Hydrotherapist?
QUESTIONNAIRE- Please provide an explanation for every “Yes” answer.
*
CHARACTER REFERENCE List 3 references, someone not related to you who has known you at least 3 years. INCLUDE: Name | Phone Number | Relationship
Please Print Name to appear on Certificate of Completion:
Digital Signature
*
Application Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
A member of our team will contact you in the next 7 days from receiving this application
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