ENROLMENT FORM
Please complete in full:
ENROLMENT INFORMATION
Date of Enrolment:
Date of Course:
Course Name:
Select the course you wish to be enrolled in
Intro To Hypnosis Course (2 Day)
Hypnosis Practitioner Certification (2 Day)
Stage Hypnotist Certification (3 Day)
Simply Easy Method License
Weigh Too Easy Method License
Life and Business Coaching Program
NLP Tools For Hypnotists Course
Total Course Fees:
How Will You Pay For Your Course?:
Payment in Full
Finance
Payment Plan
PARTICIPANT INFORMATION
Family Name:
Given Name:
Date of Birth:
Gender:
Male
Female
Address:
Position Title:
Organisation:
Email Address:
Home/Work Phone:
Mobile:
WHERE DID YOU HEAR ABOUT US?
Brochure
Website
Industry Body
Word of Mouth
Conference
Other
CURRENT EMPLOYMENT STATUS
Full time employee
Part time employee
Self employed
Employer
Unemployed
Other
LANGUAGE
Do you speak a language other than english at home?
No, English Only
Yes, I also speak:
If Yes, how well do you speak English?
Very Well
Well
Not Well
DISABILITY
Do you consider yourself to have a disability, impairment or long term medical condition?
No
Yes
If Yes, please indicate the areas of disability, impairment or long term medical condition:
Hearing Impairment
Physical Impairment
Intellectual Impairment
Vision Impairment
Acute Medical Condition
Other
Please provide brief details:
EDUCATION AND TRAINING
Are you a trained hypnotist?
No
Yes
If yes, how long have you been a Hypnotist?
Since leaving school have you completed a qualification?
No
Yes
If yes, please indicate which level qualification:
Certificate I
Certificate II
Certificate III
Certificate IV
Diploma
Advanced Diploma
Bachelor or Higher Degree