Avatar® Master’s Application to Register For the Avatar Course Internship 2019

Course Location and Date:
Full Name:
(Please use your Full Name and Course Location and Date for the subject line of this email)

My Master’s Name:
My QM is:
My Master Course Date:
My Master ID #:
License (Assist, Intern or Provisional):
Currently Licensed Y/N:
Street Address:
City:
State:
Post Code:
Country:
Country of Passport:
Mobile #:
Email:

Emergency Contact Name:
Mobile #:
Relationship to you:

I am applying to participate as a(n) (Intern, Resurfacing®, Reviewing Master):
I am currently a(n) (JAI, Tweenie, AI):

I authorise you to charge my Intern Fee 7-days prior to the start of the course:

Card Holder’s Name:
Credit Card #:
Expiration date:
CVV:
(or enter details via the Credit Card Form: https://www.avataroceania.com/credit-card-form/)

or Direct Bank Transfer:
(Auz: BSB: 06 3509 Acc No: 1022 9859 / NZ: 12-3073-0091525-00)

Monies / Royalties Outstanding Y/N:
(If yes please bring up with your QM)

This is my First / Second or more Internship:

I will bring ________ new students. Their Names are:

I can translate in the following Languages:

IMPORTANT INFORMATION: Please answer the following questions so we can be in the best possible position to support you while you are on this Avatar Course. Use an extra sheet if necessary. 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 counselling.

1. Are you currently under any medical or psychiatric supervision (Including psychotherapy or counselling)? If yes, please explain. Also include dates, duration, and outcome:

2. Are you currently taking any prescription or recreational drugs? If yes, please give the name of the drug, frequency of usage and purpose of taking:

3. Have you ever received psychiatric and/or psychological treatment? If yes please state purpose, date, duration and outcome:

4. Have you been subject to traumatic injury or violent attack? If yes, please give details:

Course Hotel Registration

Room rate:
Room type:
Cancellation policy:

Please use same credit card as above
or
Card Holder’s Name:
Credit Card Number:
Exp. Date:
CVV:
(or enter details via the Credit Card Form: https://www.avataroceania.com/credit-card-form/)

Please find me a roommate Y/N:
Or I already have a roommate, their name is:

Arrival Date:
Departure Date:

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