Hypnotherapy / Hypno-Counseling Instructor Training Course Application BodySmart Wellness LLC International Medical and Dental Hypnotherapy Association Bucks County Community College Hypnotherapy / Hypno-Counseling Instructor Training Course Application Mailing address BodySmart Wellness 680 Heacock Road, Suite 204 Yardley, PA. 19067 215-493-1204 messages@masters-center.com.com / www.masters-center.com All information must be completed. If some information is "The Same" (e.g.: business and personal address) then type "Same" in that field/box. 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SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Website Hypnotherapy/Hypno-Counseling credentials and the name and phone number(s) of each providerList all relevant continuing education completed within the last 2 years and the name(s) and phone number(s) of providersDo you currently have an active practice Y/N: Yes No N/A What is the primary focus of your practiceHow many hours per week do you practice on average List any previous experience as an instructor (Be specific):Supply 3 personal references. Include name, phone number and email addressSupply 3 Business references. Include name, phone number and email address Required: Please forward copies of your certification certificates and any CEU/continuing education certificates or documentation to us via email or postal mail (address above). (Email is preferred.) When by email use jpeg or GIF file format. Acceptance to the course is contingent on approval of previous training documentation. Note: Acceptance to this course is at the discretion of BodySmart Wellness and/or IMDHA. Please note: Graduates must successfully complete all academic, practical and financial requirements of the course and pass a final exam to receive certification (e.g.: enrollment does not in itself guarantee graduation or certification). Final exam may be retaken up to 3 times if a student is unsuccessful in passing the final exam. There is a 3 month waiting period between repeat exam attempts. All required enrollment forms, class policy forms etc. must be completed and on file with this office prior to entering the course. Those accepted are required to purchase their course materials in advance in preparation for the class and will be required to pass an entrance quiz to demonstrate that he or she has in fact studied the materials in preparation. This is to assure that class time can be used in the most efficient manner. The entrance quiz may be repeated up to 5 times if needed but must be successfully completed prior to the start of the program. Students who do not complete this requirement will not be admitted to the subsequent class. There are no refunds for materials and standard pro-rated tuition refunds apply (Maximum 50%). In the event that a student fails to successfully complete the entrance quiz there are 3 options available: (1) A partial tuition refund. (2) Re-take the exam in 30 days (3) Enter the next cycle of the class at no additional cost (at the discretion of course administrators). Successful Completion makes the graduate eligible to teach as a regional instructor for the basic certification and the Advanced Certification courses approved by IMDHA, BodySmart Wellness and Bucks County Community College. Those instructors accepted will be assigned to teach in a specific geographic area through BodySmart Wellness as approved independent contractors for the purpose of preparing students for the online portion of the course and providing hands-on mentoring for the purpose of preparing students for graduation in line with the approved curriculum. Graduates must teach at least 1 class each year and are required to complete a 2 day instructor refresher course every 2 years to retain approved instructor status. This will be done online. I attest that the information provided is truthful and accurate and understand that falsification on my application may, at the discretion of the program administrator(s), result in being dropped from the class with no refunds of materials or tuition. I have read and understand this document and further agree that if accepted to abide by all standard class policies and procedures. I further attest that I am over 18 years old. Clicking the Submit Button below constitutes agreement to these terms and conditions. Please attach a photo of yourself to be included in your file.Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.Applicant electronic signature or typed full name Captcha Δ
