Participant application for our basic Acuscope/Myoscope Training Courses.

First Name: Last Name:

Email Address:


Street Address:


City:


State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code:

Contact telephone numbers: format: 212-555-1212
Day: Evening:

Emergency Contact Name:

Emergency Contact Phone Number:

Current Occupation:

Equine/Canine/Feline Education/Experience:


Massage/Bodywork/Energy Education:


Type of Therapeutic Modalities Practiced?


How Will You Use the Training?


This course can be physically and mentally strenuous,
do you have any physical limitations?


Allergies?


Dietary Requirements?


Other preferences or limitations?


A non-refundable, transferable (to another course with a 2-week notice) deposit of $500 is required to be submitted with this application and will be applied to the total course cost. The balance of course cost is due in full prior to the first day of class.

Animal Therapy Systems reserves the right to dismiss a student from the course, without refund of tuition, should the student demonstrate unsatisfactory conduct.

I certify that I am in generally good health and am capable of participating in the Animal Training Course, and that the information I have given is true and factual.

RELEASE OF LIABILITY: I / We hereby release and hold harmless ATS (Animal Therapy Systems), Molly Wells, Joyce Jackson and/or their agents from any liability due to accident or damage to self, horse, dog, cat and/or personal and from loss of property during the Animal Training Courses. ATS may not be held responsible for travel arrangement cancellations, caused by class cancellation due to weather, or any other reasons. My / Our submission of this form denotes acceptance of this release.

Additional comments or questions?

Indicate the class would like to sign up for:
January 4-12 — Glen Rose, Texas
February 21-28 — Las Vegas, Nevada
May 18-26 — Glen Rose, Texas
August 9-18 — Blue Grass, Iowa
August 30-3 — Sacramento, California
September 6-17 — Reno, Nevada
October 11-22 — Slippery Rock, Pennsylvania
Early November 2010 — Glen Rose, Texas
TBA — Calgary, Canada
TBA — Las Vegas, Nevada
TBA — Louisville, Kentucky