Application for Enrolment for Diploma of Clinical Hypnotherapy

Please Print all your details and attach your passport photo (signed and witnessed by JP on back) to the form and send to

ACH, P.O. Box 929 Leichhardt, NSW. 2040

Title: Dr. Mr. Mrs. Ms. Others

Male / Female

DOB :	First Name :

Address:

Suburb :	State :	Post Code :

Tel (W) :	Tel (H) :	Fax :	Mobile :

Country of Birth :	Nationality :

Drivers License number :	Expiry Date :

Passport number :	Expiry :

Medical History :
(please outline any psychological disorders or diagnosis as well as general your general medical history)

Formal Education :
(please include any courses or training programmes you completed and the date started/finished as well as your grade)

Work Experience :

EMERGENCY CONTACT DETAILS

Full Name :

Relationship to you :

Address:

Suburb :	State :	Post Code :

Tel (W) :	Tel (H) :	Fax :	Mobile :

E-mail:

I give permission for Australian College of Hypnotherapy (ACH) staff member/s to ring for an ambulance on my behalf in the event of a MEDICAL EMERGENCY where I require medical attention. I fully understand that I will bear the cost of this service and do not hold Australian College of Hypnotherapy (ACH) or its staff/educators responsible for any costs incurred.

I have read, understand and agree to abide by the above Student Responsibilities.

Student Name :		Student No :

Student Signature :		Date :

Witness Name :

Address :		Phone No :

Witness Signature :		Date :

I will be attending Course A – Intensive Course B – Weekend

My Student No :		Group Number :