ATM Application for RPP

Basic Information

First Name *

Last Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Phone *

Email Address *

SCHOOL Address *SCHOOL ADDRESS

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Date of RPE registration *

Training Program Title *

Will any of the training be delivered via Distance Learning? If yes, which methods?

Total Hours of Training In person and via Distance Learning?

Website

Do you have state or local registration?YesNo

Does your training program have a state license?YesNo

Can you demonstrate that you are exempt from needing a state license?YesNo

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Course curriculum, referencing the Standards for Education hours and content

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Copy of class schedule

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Copy of information booklet/materials that goes to students

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Copy of marketing brochures, flyers or handouts given to the public

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Copy of diploma or completion certificate issued to students

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Copy of the transcript given to students upon completion of the program requirements

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Copy of evaluation forms, tests or other measurements of success

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Copy of state approval of registration if applicable

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Two letters of reference attesting to your character, experience as a Polarity Therapy Educator and capacity to administer a Polarity Therapy program

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A resume of professional experience