Student’s Application to Register for The Avatar® Course 2019

Full Name:
Registering For (ReSurfacing or Avatar Course):
Course Location and Date:
(Please use student’s Full Name, Registering For and Course Location and Date for the subject line of this email)

Street Address:
City:
State:
Post Code:
Country:
Country of Passport:
Mobile #:
Email:
Language:
Course Start Date:
What do you do for a Living?:
Age (if under 18):

My Master’s Name:

Emergency Contact Name:
Mobile #:
Relationship to you:

New Student
Registering for: [Delete Non Applicable]

• ReSurfacing® Workshop:
AUD $330 NZD $402.50

• The Avatar® Course:
AUD $3190 NZD $3050

Payment details: Cash / Direct Transfer / Credit card
Note to Master: If you do not have credit card facilities and the student is wanting to pay by credit card then email Shona (shonam@avataroceania.com) to arrange this.

Reviewing Student registering for:

1. ReSurfacing Review: $110*
2. Avatar Review: $495*
(*in the currency of course location)

Card details for Reviewing student
Card Holders Name:
Credit Card Number:
Expiry Date:
CVV:
(or enter details via the Credit Card Form: https://www.avataroceania.com/credit-card-form/)

IMPORTANT INFORMATION: Please answer the following questions so we can be in the best possible position to support you while doing your 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:

Avatar® and ReSurfacing® are registered trademarks licensed to Star’s Edge Inc. All rights reserved