Application for the Aston-Patterning Practitioner Certification Program

Name*

First NameLast Name

E-mail*

Date of Birth*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Occupation

Statement of Purpose*

What has led you to pursue the Certification in Aston-Patterning?

Education/Degrees*

Please list your professional education/degrees, such as a higher education degree, academic training in education, health care or a related field, working knowledge of anatomy/kinesiology or a diploma from an accredited school of massage.

Scanned copy of massage school, physical therapy school or medical school diploma*

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Scanned copy of massage license or medical license*

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Scanned copy of liability insurance

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If you do not have current liability insurance, contact our office for options. Liability insurance is required before training begins.

Recent Photo*

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Which foundation courses have you completed (Aston Kinetics 101, 102, 103 & 104?)*

Aston Kinetics 101&102Aston Kinetics 103: Bodyworks IAston Kinetics 104: Bodyworks II

If you have not completed these courses, what courses do you still need to take? When do you plan on completing these courses?

Have you received a private Aston-Patterning session with a currently certified Aston-Patterning practitioner? *

YesNo

If not, when do you plan on scheduling a session?

Please note how you plan on paying for training:*

I can pay in full.I have questions about payment plans.

Questions on training payment:

Additional Questions:

Application Fee (Please note that our online payment process is secure, utilizing Stripe as our merchant account.)*

A-P Cert Application Fee$150.00

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