Note: an interview with Instructor Mary Elizabeth Raines is required before acceptance into the past-life regression counselor 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
PAST-LIFE REGRESSION COUNSELOR TRAINING
REGISTRATION FORM

 

FULL NAME (Please Print)_________________________________________________________

 

NAME BY WHICH YOU WOULD LIKE TO BE CALLED________________________________

 
MAILING ADDRESS ____________________________________________________________

 

TELEPHONE (HOME)____________________(WORK)____________________(CELL)______________

 

E-MAIL (will be used only for class communications)________________________________________

 

DATE OF BIRTH ______________________________

 

CURRENT PROFESSION_____________________________________________________

 

EDUCATION OR OTHER TRAINING YOU HAVE HAD WHICH MIGHT BE PERTINENT TO PAST-LIFE COURSE:

 

_____________________________________________________________________________________________

 

BRIEFLY DESCRIBE YOUR INTEREST IN STUDYING TO BECOME A PAST-LIFE REGRESSION COUNSELOR:

 

 

 

_______________________________________________________________________________________________

 

ROOM INFORMATION

Please let us know if you would like to be on a list of people who would like to find roommates and/or rideshares. By signing below, you permit us to give your email and telephone number to others wanting roommate and/or shared rides. (Note: We cannot guarantee that you will have a roommate and/or shared rides.) Please check all that apply.

I would be interested in sharing a room

I would be interested in carpooling to/from airport

I would be interested in carpooling to/from class

    (Name)__________________________________________________________________(date)___________

 

 

PLEASE SHARE ANY PERSONAL CONDITIONS/SERIOUS ALLERGIES/CIRCUMSTANCES OF WHICH YOU WOULD LIKE US TO BE AWARE:

 

__________________________________________________________________________________________

 

To be eligible for certification, students are asked to attend all 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 past-life regression session. Class begins at 8:30 a.m. on Monday, Nov. 17th; class ends at 12:00 noon on Saturday, Nov. 22.
 
I have read, understand and agree to the above eligibility requirements, as well as the personal responsibility clause below:

 

Signed_______________________________________________________Date_______________________

PERSONAL RESPONSIBILITY CLAUSE: Each individual is responsible for her/his own emotional, physical and mental wellbeing. By signing this contract, you agree to take personal responsibility for yourself, and furthermore agree that you, your family and your heirs will hold the Academy for Professional Hypnosis Training, Laughing Cherub Hypnosis 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 minimum)

  • $595 - if you enroll by August 15, 2008

  • $695 - if you enroll by August 30, 2008

  • $750 - if you enroll by Sept. 30, 2008

  • $795 - if you enroll by October 30, 2008

  • $895 - Enrollment after October 30, 2008
     

    • Registration and deposit must be postmarked by the above date to qualify for discount.

    Call us if you have extra deductions for bringing along a friend or choose to pay by PayPal: (920) 867-3900

 

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

Please make out check to "Laughing Cherub" and mail together with this form to:

Refund policies: a minimum deposit of $225 is required to enroll. The deposit amount, minus a $25 bookkeeping fee, is completely refundable up until three weeks before the beginning of class. From three weeks to the start of class, refunds will be given for any amount in excess of $225; the remainder is non-refundable, however $200 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). After class begins, there will be no refunds.

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