Name _____________________________________________Referred by _________________________________
Address _______________________________________________________ Date of Birth ____________________
______________________________________________________________ Telephone ______________________
Employer ______________________________________ email___________________________________________
In Case of Emergency call __________________________________________ Telephone ______________________
Highest Level of Education: GED _____ HS _____ BA _____ MA/MS _____ PhD _____ Other __________________
Any experience with coaching or hypnotherapy? ________________________________________________________
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? ___________________________________
Do you recreationally use drugs or alcohol? ____________________________________________________________
Has anyone ever suggested that you had a problem with either?_____________________________________________
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? ___________________________________
Part of the registration process is an interview with the school Director Zoilita Grant M.S. CCHt. This interview maybe done
in person or on the phone...Please call 303 776-6103 to schedule.

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 intense and emotionally based nature of this training may stimulate me with a need to deepen 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 wellbeing during class hours. I am aware that there are three cats in residence at the school. Although the cats are never in the main classroom, I understand that if I have a cat allergy, I need to let the school know and take care of myself around this issue.

Signature of Registrant ____________________________________________ Date Signed _____________________

Beginning 1/1/08 School Administration Fee of $200 must accompany Form.
(This is nonrefundable
after registration accepted, unless class is canceled)
Registration Accepted:
Yes _____ Date of Acceptance _____________________________
No _____ Reason (s) __________________________________________________________________
Signature of School Official _______________________________________________________________________
Colorado Coaching and Hypnotherapy Training Institute
200 Lincoln St. Longmont, CO 80501
(303) 7766103
www.coloradohypnotherapy.com
Approved and regulated by the Colorado Department of Higher Education,
Division of Private Occupational Schools