3 WEEKEND REGISTRATION

Mail to:
American Society of Alternative Therapists
P.O. Box 703
Rockport, MA 01966
(978) 281-4400

The information can be typed on your computer and printed by using the keyboard shortcuts of control + p for Windows, or command + p for a Macintosh. If you prefer to fill out the form by hand, please print.

   

Name


 (As you want it to appear on certificate)

Address

City

State

Zip

Home Phone

Office Phone

Occupation

Course Location

Check One Only
Full Payment $895     First Payment $395
Method of Payment
Check Money Order Mastercard Visa

Credit Card Number

Expiration Date

Signature

No cash please. Make checks and money orders payable to "ASAT."

IMPORTANT - Please read and sign the Agreement and Release statement below. The statement must be signed and dated before your registration can be processed. Thank you.

AGREEMENT and RELEASE

I understand that the materials and titles in this course are trademarked and copyrighted and therefore protected under Federal Law. I agree not to use information from the ASAT™ C.O.R.E. Counseling course to in any way violate trademark and copyright laws or any medical practices act, and will conduct my practice according to existing laws and regulations governing said practice. I understand that once the course begins, all payments made, full or partial, are nonrefundable. I HAVE BEEN DULY INFORMED BY ASAT™ THAT SOME PARTICIPANTS MAY FIND THE COURSE TO BE AN INTENSE EXPERIENCE, PHYSICALLY, MENTALLY, AND EMOTIONALLY. I WARRANT AND REPRESENT THAT I AM PHYSICALLY, MENTALLY AND EMOTIONALLY ABLE TO ATTEND THE COURSE AND AM NOT CURRENTLY SUFFERING FROM, TAKING MEDICATION OR BEING TREATED FOR ANY MENTAL ILLNESS OR EMOTIONAL DISORDER WHICH ILLNESS OR DISORDER WOULD BE ADVERSELY AFFECTED OR OTHERWISE AGGRAVATED BY MY PARTICIPATION IN THIS COURSE. IN ANY EVENT, I HEREBY WAIVE, remise, release, and forever discharge for myself, my successors, heirs and assigns the said Dr. Martin Hart, individually, and ASAT™ and its successors, assigns, officers and directors, of and from any and all causes of action, suits, contracts, controversies, agreements, promises, damages, judgments, executions, claims and demands, whatsoever, in law or in equity, which against the said Dr. Martin Hart or ASAT™ I ever had or now have or which my successors, heirs or assigns hereafter can, shall or may have for, upon or by reason of any matter or thing whatsoever from the beginning of the world to the date of these presents and more specifically those claims arising out of the above described ASAT™ C.O.R.E. Counseling course. This release may not be changed orally.

Signature

Social Security Number

Date