Our Basic Acuscope Training & certification courses include Acuscope refresher Courses, Advanced
Acuscope Classes, Equine Aromatherapy, Equine Nutrition & Acupressure with Essential Oils.

If you have not done so, please refer to our training program schedule and course description before
completing our online registration. If you have questions, don't hesitate to contact us. *Please include
your email address in the space provided at the end of this form.

Name
Date:

Street Address


City and State
Zip:

Contact telephone numbers
Day: Evening:

Emergency Contact:

Current Occupation:

Equine/Canine/Feline Education/Experience:


Massage/Bodywork/Energy Education:


Type of Therapeutic Modalities Practiced Practiced?


How Will You Use the Training?


This course can be physically and mentally strenuous, do you have any physical limitations?



Allergies?


Dietary Requirements?


Other preferences or limitations?


A non-refundable, transferable, deposit of 30% of total course tuition is required to be submitted
with this application and will be applied to the total course cost. The balance of course cost is due
in full one month in advance of the class dates.

Animal Therapy Systems reserves the right to dismiss a student from the course, without refund
of tuition, should the student demonstrate unsatisfactory conduct.

I certify that I am in generally good health and am capable of participating in the Animal Training
Course, and that the information I have given is true and factual.

RELEASE OF LIABILITY: I / We hereby release and hold harmless ATS (Animal Therapy Systems),
Joyce Jackson and/or their agents, from any liability due to accident or damage to self, horse, dog,
cat and/or personal and from loss of property during the Animal Training Courses. ATS may not be
held responsible for travel arrangement cancellations, caused by class cancellation due to weather,
or any other reasons. My / Our submission of this form denotes acceptance of this release.

Additional comments or questions?

Course Name Here Additional Course Names... etc... boxes will be added later.

Training Date - Location Requested:



You may submit your application online, or if you prefer, print the completed form and
fax to: 530-547-7106.