Student Intake and Release

Student Intake and Release

Must be submitted with registration
Student Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
E-mail
example@example.com
Course registered for (Certification- CHt, MHt, LbLt, CCR), Date, and Location
course, date and location
REQUIREMENTS FOR CERTIFICATION NATH reserves the unconditional right to grant or deny admission; however, NATH does not discriminate on the basis of race, age, sex, religion, national origin, or handicap. All students must be fit to give and receive hypnosis. Do you have any physical, mental or behavioral condition requiring continued treatment by a doctor, psychiatrist or psychologist? If not, please use N/A in the box below. if so, please explain in detail. Please provide a list of medications you are taking. (all info is confidential and for your safety)
Goal Statement for this Hypnosis Certification course:
How did you hear about us?*
I, First Name Last Name give NATH (National Association of Transpersonal Hypnotherapists, LLC.), and/or Transpersonal Power, LLC to observe, edit, and evaluate for course use, without conditions, the Audio and Visual pictures and recordings of myself that took place during the course. i understand that no names will be used.
I acknowledge everything to be true to the best of my knowledge, and I agree not to hold NATH or any of its trainers liable for any outcomes related to the hypnosis sessions during the course or for any success or challenges I may experience in the hypnosis field after the course. Signature
Should be Empty: