Name *

as it should appear on the Certificate

First Name

Last Name

Phone *

(###)

###

####

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

####

How do you wish to Pay? *

Send invoice to email address above

I will pay by cash or check.

I will pay by Venmo, to: @brian-loftin-12

Disclaimer *

Please check the box below, indicating that you have read and agree to the following terms and conditions.

This application is complete to the best of my knowledge.

I understand that my participation in class is not a substitute for my own personal treatment, and I absolve Brian Loftin and any participating person (teacher or student) in this course of any responsibility as to diagnosis, evaluation, and/or treatment of any conditions I may or may not have.

No portion of this class shall be a substitute for my own, professionally-supervised and administered health care.

I agree that I, the applicant, am not to solicit my own services or advertise my own therapeutic methods to fellow teachers or students—nor be solicited to in the same manner.

I will not discuss religion or politics in class, or in the immediate environs of this classroom setting.

I agree not to electronically record any portion of this class, unless specifically allowed by the lead instructor.

I agree not to photograph other students in this course without their express permission.

I agree not to republish, copy, fax, or duplicate in any way, the intellectual property of this course, or any others that I may participate in. This may include course texts, handouts, slides, or audio recordings owned and provided for the benefit of each student by Brian Loftin. All materials provided to students are for their own personal usage.

I acknowledge that there may be food or drink offered at the refreshment table that could be an allergen (i.e. nuts, sugar, gluten, etc.). I am solely responsible for my own food and drink choices and will not hold the host of the workshop or any instructor responsible for any choices I may make regarding the refreshment table. However, in the event that I can not be around certain foods, I agree to inform the host or instructor in advance of the class.

Out of respect for my fellow classmates, I will refrain from wearing perfume, cologne, or other scented oils or items in class, and will attend class with good hygiene (nails trimmed, deodorant, etc.)

I declare that I have not been exposed to, nor have I contracted the Corona Virus. I agree to wear a mask throughout the training. *

I DO agree

I DO NOT agree