The Kent Institute of Clinical Hypnotherapy

Student Application

Start date: (Month & Year)

Please ensure that all relevant sections of this form have beencompleted fully before submitting.

Date of Application:

Your Details:

Name (Mr/Ms/Miss/Mrs/Title):

Address:

Post Code:

Telephone:

Email:

Date of Birth:

Nationality:

Marital Status: [ ] Single [ ] Married [ ] Living with partner [ ] Divorced/separated

Where did you hear about us? Please be specific, so if you found us on a particular website, which one?

Have you any previous training in hypnosis, hypnotherapy or psychotherapy?

If 'yes' please givebrief details:

Current occupation:

Brief occupation history:

Have you had, or do you have, any serious illnesses?Or are you disabled in any way? (Includingpsychiatric/emotional) Y/N

If 'Yes',please give brief details here:

What other subjects have you studied as an adult? (Whether or not you obtained any awards/qualifications)

Please indicate the course you want to study:

Professional Practitioner:

[ ] Classroom study

[ ] Personal Tutorial

We will contact you to arrange your first tutorial appointmentASAP

Course Fees:

The Professional Practitioner Course fee is £2450.00* for the entire course.

This covers all course books and audio support material - there is nothing else to

Pay.

You may pay in advance for the full course cost, or via 10 monthly payments of £245.00

Other payment options may be available - please contact us for further details.

Your Payment Details:

How do you wish to pay? (Please note that a deposit of at least 10% is required with this application)

[ ] In advance

[ ] Per monthly module - first payment enclosed

Payment of: £ enclosed by cheque or details and date of bank transfer OR paid online via PayPal (please delete as appropriate)

Please make cheques payable to 'KICH' or you may make a Bank Transfer in favour of:

KICH

Sort Code: 09-01-50

Account Number: 0694 6585

Mark your bank transfer payment 'Deposit PraC' and add your name please.

Declaration: I understand that if I am not accepted as a student onto the course for any reason whatsoever, any monies I have paidwill be refunded in full.

I understand and agree that all applicants for classroom training may be required to participate in a brief interview, either by personalattendance or by telephone, prior to acceptance upon the course.

I also agree and accept that if any course admin, provider, or professional assistant deems any of my behaviour either inappropriate or against their procedure, they reserve the right to discontinue my participation from the course.

SIGNED: Date:

**Please ensure that you have completed all relevant sections of this form and made your deposit payment, applications will not be processed without a deposit.

Please return your completed form to:-

White Lodge

33 Wigmore Road

Gillingham

Kent

ME8 0SP

Contact Phone:- 01634 420039

**If for any reason this course does not go ahead a full refund of your deposit will be made.

For office use only:

Deposit: £ ______(cash/chq/cc/pp)

Financial: ______

Database: ______

Student List: ______

Interview/References: Refs requested: ______

Refs received: ______

Interview date: ______

Welcome pack sent: ______

Signed PTA received: ______