Master Application

Contact Information

FIRST NAME: *

FAMILY NAME: *

MY MASTER'S NAME: *

MY QM IS: *

MY QM'S EMAIL IS: *

MY MASTER ID (If you do not know this email Miken: miken@avatarhq.com): *

LICENSE: * Assist Intern Provisional

CURRENTLY LICENSED: * Yes No

STREET ADDRESS: *

CITY: *

STATE/AREA

POSTAL/ZIP CODE: *

COUNTRY: *

COUNTRY OF PASSPORT: *

MOBILE: *

EMAIL: *

ARE YOU 18 YEARS OLD OR OLDER? * YES NO

Please fill out the Parental Authorisation Form and email to office@avataroceania.com

Click here.

Please enter your age, your guardian's name and their relationship to you.

YOUR AGE:

GUARDIAN:

RELATIONSHIP:

EMERGENCY CONTACT NAME: *

EMERGENCY CONTACT PHONE: *

RELATIONSHIP TO YOU: *

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Language & Translation

LANGUAGE: *

TRANSLATION NEEDED? * YES NO

I REQUIRE VERBAL TRANSLATION IN (LANGUAGE):

I REQUIRE WRITTEN MATERIALS IN (LANGUAGE):

I CAN ALSO TRANSLATE IN (LANGUAGE):

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Important Information:

Please answer the following questions so we can be in the best possible position to support you while doing your Avatar course.

NOTE: The Avatar Materials are for self-evolvement; they are not designed to address specific emotional issues, nor are they to be considered as a replacement for medical treatment or sensible psychological counseling.

ARE YOU CURRENTLY UNDER ANY MEDICAL OR PSYCHIATRIC SUPERVISION (INCLUDING PSYCHOTHERAPY OR COUNSELING)? * YES NO

IF YES, PLEASE EXPLAIN AND INCLUDE DATES, DURATION AND OUTCOME *

ARE YOU CURRENTLY TAKING ANY PRESCRIPTION OR RECREATIONAL DRUGS? * YES NO

IF YES, PLEASE GIVE THE NAME OF THE DRUG, FREQUENCY OF USAGE, AND PURPOSE OF TAKING *

HAVE YOU EVER RECEIVED PSYCHIATRIC AND/OR PSYCHOLOGICAL TREATMENT? * YES NO

IF YES, PLEASE STATE PURPOSE, DATE, DURATION AND OUTCOME *

HAVE YOU EVER BEEN SUBJECT TO TRAUMATIC INJURY OR A VIOLENT ATTACK? * YES NO

IF YES, PLEASE GIVE DETAILS *

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Contact Information

Language & Translation

Important Information:

Course & Tuition