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?)

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?

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

Please note how you plan on paying for training:

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

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

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

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