NATH Registration (print or type)
Fax: (540) 997-0324

Name_____________________________________________________________________________
(as you want it to appear on your certification)

Address___________________________________________________________________________

City______________________________________State________________Zip__________________

Ofc. Phone(_____)_____________________ Personal Phone(______)_________________________

Emergency Contact_________________________ Soc.Sec.No._______________________________

Medical or Mental Health Conditions_____________________________________________________

College____________________________________________________________________________

__________________________________________________________________________________
City/State Dates Major Degree Received

Trade School_______________________________________________________________________

Hypnosis or Reiki Training/Experience___________________________________________________
(Please attach certifications from other institutes if applicable)

High School________________________________________________________________________
(Recommended- If N.A., then a G.E.D. is required)
Preferred Class: __________________________________________________________________________________
(Title) (Date) (Location)

List the number hours you have in conducting regressions.____________________________________
(Not applicable for Past Life course, or entry level hypnotherapy course)

How did you become acquainted with N.A.T.H.? (Please Be Specific)
_________________________________________________________________________________

_________________________________________________________________________________

Completion of this form, with a 1/2 page "Goal Statement" on the back, and a $295.00 deposit will preregister you for hypnotherapy courses. Reiki 1 & 2 courses require full tuition payment with this form. Deposits are non refundable, but may be applied to a later course within a one year period. VISA, Master Card and American Express are accepted; and personal checks will be approved with the Credit Card number and expiration date clearly marked on it. Make checks payable to NATH. All Funds must be in US dollars. Certifications may be released upon completion of all scholastic and financial requirements. If students are not contacted after preregistering, they are considered to be enrolled.

Credit Card #___________________________________________ Exp Date____________

Payment Type: ___Visa ___MC ___AmEx ________Check# Amount Authorized_________

I hereby subscribe that all of the information contained in this application is true and complete. I have read and understood all of the policies in the current course flier.

___________________________________________ _______
Student Signature/Date