Vibrational Attunement Massage

Training & Certification Seminar Registration Form

Authorized Card Holders Signature:______________________________Date: ___/_____/________

By my signature, I _______________________________________________ request placement in the 24.5 contact hour course of instruction in Vibrational Attunement Massage Therapy.Further, I have read and fully understand the policies as stated on the reverse (page 2) of this form and specifically authorize the retention and release of my educational records as specified in the policies of Dustin Fox and/or as may be required by the NCBTMB in accordance with those policies.

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RELEASE OF INFORMATION:It is the police of Dustin Fox, CMT, CAMT to maintain the transcripts, registration information and other educational information provided to or by the attendee in individual file folders and in a locked and secure manner for a period of not less than four (4) years.Access to said files shall be limited to those individuals specifically authorized from within the Vibrational Attunement Massage educational program and the attendees upon written request.Further, each attendee is herein advised that the retention of educational records is a requirement of the certification standards as promulgated by the NCBTMB and that said educational records are utilized to substantiate re-certification, verify compliance with NCBTMB policy and to prevent un-authorized access to the attendee files.The signature on the attendee on page one (1) of this form shall indicate that the attendee is requesting and authorizing the release of only that information that is required by the NCBTMB to the NCBTMB for re-certification verification and further, that information that may required by the attendee for use by others shall be released only with the written consent of the attendee and shall be forwarded to the attendee, in its entirety, to the attendee at the last known physical address provided by the attendee.

REGISTRATION TIME LINE:Registration applications will be accepted for the pending class date 45 days in advance of the class commencement date and continue until 15 days prior to the class commencement date.

COURSE FEES, DEADLINES, REFUNDS AND DEPOSITS:REGISTRATION AND PAYMENT IS REQUIRED PRIOR TO ATTENDANCE

Seminar Fees For Montana:$350.00 when paid by the published deadline date.$375.00 when paid within the 35 day period prior to the class commencement date.A $25.00 non-refundable registration fee must be submitted with application for the 3 day course of instruction if full payment is not made until the 5 day period until the 5 day period prior to commencement.

Seminars in other States and/or Countries: In the states of Idaho, Oregon, Washington, Wyoming and Utah the pre-registration fee shall be $375.00 with no less than 6 attendees attending per class.In all of the following states no less than a total of 16 attendees is required.In the states of Colorado, Nevada, California, New Mexico, Arizona and Texas the registration fee shall be $425.00.In the states of Michigan, Wisconsin, Oklahoma, Missouri, Nebraska, Kansas, North & South Dakota, Illinois, Indiana and Ohio the registration fee shall be $450.00.In the states of Pennsylvania, New York, New Hampshire, Vermont, Rhode Island, New Jersey, District of Columbia, Kentucky, Tennessee, Virginia, and West Virginia the registration fee shall be $475.00.In the states of North & South Carolina, Alabama, Georgia, Mississippi, Louisiana and Florida the registration fee shall be $475.00.Registration fees for seminars conducted outside of the Continental USA shall be determined when scheduled.

Deposit / Refund / Cancellation Policy:All fees are held on deposit until five (5) days before class has begun.All deposited fees are applied as a credit to the total course fee for those who complete the full curriculum.Attendees who are unable to complete the scheduled 3 day class being attended shall have the option of returning to complete the course of instruction within 90 days.In the event that the course provider cancels or causes to be cancelled a scheduled course presentation, all paid participants shall receive a full and complete refund within 60 days of notice of said cancellation.

RESPONSIBILITY: Dustin Fox, as the certifying lead instructor and provider of this educational offering shall be responsible for course development and ongoing course revision, course content, methods of presentation, learning outcome determination, attendee evaluation, testing, instructor qualification, removal and retention policy, attendee and operational record keeping, accounting, information content relating to all advertising and marketing of the course offering, co-provider selection, facilities and agreements that relate directly of the course offering.Additional policy details relating to each of the subjects of responsibility shall be made available to attendees upon written request.

AMERICAN DISABILITIES ACT (42 USCG SECTION 12101):In compliance with the policy as defined by the American Disability Act, it is the policy of Dustin Fox, to make reasonable accommodation(s)for those attendees who have disability(s) except where such disability would cause an undue burden.

CIVIL RIGHTS ACT, TITLE VII:In compliance with the Civil Rights Act, Title VII, the policy of Dustin Fox is; We do not discriminate on the basis of race, color, religion, sex or national original.

ADDITIONAL INFORMATION: Dustin Fox, by virtue of licensing agreements with various massage and spa furnishings manufacturers may have a vested interest in the demonstration and sales of the Fox Acoustical Touch System (patent Pending).Although the VAM Seminar is open to the public, attendees of the Vibrational Attunement Massage Seminar who seek certification as a CVAMT must be capable of performing energetic massage for no less than 30 minutes, provide evidence of being a practitioner or a currently enrolled student of massage, bodywork or other Complimentary Alternative Medical(CAM) Healing or Medical practice. Students of massage must be actively enrolled in a massage educational program and have successfully completed the Anatomy / Physiology portion of their education.  School Directors / Administrators will receive and award VAM Certification Documents to present to students upon their graduation from the educational program. All materials received prior to and/or during the VAM seminar are to be considered the restricted proprietary information that is created and copyrighted for and/or by Dustin T. Fox and as such is not to be reproduced, copied or utilized in any manner without the specific and express written consent of Dustin T. Fox and/or his assigns.

MAIL COMPLETED APPLICATION & PAYMENTS TO

DUSTIN T. FOX, CMT, RM, LRM

C/O HEART 'N' HANDS MASSAGE

1627 W. MAIN ST. PMB 244

BOZEMAN, MT. 59715-0411

(SEND NO CASH IN THE MAIL) VISA / MASTERCARD ACCEPTED BY PHONE TO 800-304-9197

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