Print name with initials as you want on your certificate________________________ Address_____________________________________________________________
email ___________________________Telephone ____________ Practice as__________
Previous School_____________________________
In Case of Emergency call________ Telephone __________________
How did you hear about this school____________
Any experience with hypnosis?____________Other_Modalities____________________
What do you plan to accomplish/experience by taking the training?_________________
Do you have any special physical needs we should know about? ___________________
Are you currently on any antidepressant, or other mood altering medication? _________
Have you ever been diagnosed with or treated for a mental illness?__________________
Do you have any felony or morals conviction or charge in your background? __________
Do you recreationally use drugs or alcohol? ____________________________________
Has anyone ever suggested that you had a problem with either?_____________________
As a potential student: I understand that the Colorado Coaching and Hypnotherapy Training Institute offers no placement services or guarantee of employment to the graduates of this course.  I understand the sometimes intense and emotionally based nature of this training may stimulate me with a need to focus on my personal growth.  I commit an oath of confidentiality of all personal information I am witness to during this training.  I take responsibility for my health and well being during class hours.

Signature of Registrant ________________________Date Signed __________________
Name of Class :  _____________________________
Registration Accepted:
            Yes _X___      Date of Acceptance__________
            No  _____       Reason (s) ___________________________________________

                                Checks to CSCHTI 200 Lincoln Street Longmont, Co. 80501
               
                    For Credit Cards: Billing name and address on the card.
Name:_______________________________________________  
 Address:____________________________________________
City:________________________________State:____________Zip:_______________
Phone:____________________________________Cell____________________
Master Card/Visa #_____________________________