ACHE Student Application


APPLICATION FOR REGISTRATION AS STUDENT MEMBER

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Click Here to Download or Print This Application

Click Here to Download or Print the ACHE Code of Ethics

American Council of Hypnotist Examiners

3435 Camino del Rio S., Ste. 316, San Diego, CA 92108, USA

Dr. John Butler, President – Gil Boyne, Founder

APPLICATION FOR REGISTRATION AS STUDENT MEMBER

Full name _____________________________________________________________________

Title _________________ Gender ______________ Date of Birth ________________________

Mailing address_________________________________________________________________

State ___________________ Country ______________________ Zip code _________________

Email address__________________________________________________________________

Tel/s: Home ___________________________ Bus: ____________________________________

Website/s _____________________________________________________________________

PRINT NAME HERE AS IT IS TO APPEAR ON YOUR MEMBERSHIP DOCUMENT

______________________________________________________________________________

Approved training courses in hypnosis/hypnotherapy attended/being attended

Name of School ________________________________________________________________

Website/s _____________________________________________________________________

Name of instructor ______________________________________________________________

Title of course completed _________________________________________________________

Beginning and completion dates of course ___________________________________________

If additional schools/courses, continue on separate sheet of paper

Total number of actual classroom hours to date ________________________________________

Total number of hours of interactive online instruction to date ____________________________

Total number of supervised practice hours to date ______________________________________

Intended total number of actual classroom hours ______________________________________

Intended total number of hours of interactive online instruction __________________________

Intended number of supervised practice hours ________________________________________

Intended completion date of training i.e. eligibility for certification _______________________

Other relevant training/education/experience __________________________________________

______________________________________________________________________________

______________________________________________________________________________

If required, continue on a separate sheet of paper

Sponsored by __________________________________________________________________

(School Principal or Director – please provide contact details below)

Describe the arrangements that have been/will be made for supervised practice

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Supervisor signature ____________________________________ Date ____________________

Supervisor name (please print) ____________________________________________________

Supervisor Certifications in Hypnotherapy____________________________________________

Supervisor Contact email ___________________________________ Tel _________________

Have you ever been convicted on a felony or morals charge? Yes ‘ No ‘

If yes, please provide details on a separate sheet, including dates, location and court references.

Declaration:

• I understand that this application for registration as a student member will be accepted only

on the condition that I meet the requirements set by the ACHE.

• I understand that the limit of student membership is for two years.

• All the information given in the application is correct and true to the best of my knowledge. I

understand that any false information given will be grounds for denial of this application.

• I agree to hold the ACHE free and harmless for denial of registration, should it occur, or for any future revocation of my registration, should the ACHE find that action appropriate as defined by the by-laws.

• I have read and signed the ACHE Code of Ethics and enclose this herewith.

• I have provided/enclose herewith payment of the appropriate fee.

Signature _______________________________________________ Date _________________

FEES: The fee for student membership for two years is $25. Checks are made payable to ACHE.

Contact Bette Epstein by email: bette@heartsong.com

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214-358-3633