Personal Information

Applicant's First & Last Name:

Applicant's Date of Birth (month/date/year):

Date of Application (month/date/year):

Applicant's Gender:
Male
Female

Applicant's Street Address:

City, State, Zip Code (City, XX XXXXX):

Applicant Phone Number:

Applicant Email Address:

Education & Experience

All Degrees Held - List up to 5 (Year, Institution, Degree, Major, Field of Study):

Previous Post-Graduate or special training experience(s) - List up to 5
(Year, Length of Time, Name of Program, Leader(s)):

Why did you select the Gestalt Equine Institute of the Rockies?

Do you have any equine assisted psychotherapy training?

What is your past horse related experience? (Please include any riding experience)

Have you ever experienced any emotional or physical trauma? (In your life OR with horses)

What do you hope to gain from this training?

Do you have any special physical or personal needs while you are at the training?

Is there anything that you feel nervous or concerned about participating in this training program?

Is there anything else you would like us to know?

References

List three references who know you and your work (Name, Profession, Address, Phone Number):

Professional Work Experience (Your present position)

Organization:

Date Employed:

Street Address:

City, State, Zip Code (City, XX XXXXX):

Phone Number:

Responsibilites:

Immediate Supervisor:

Supervision:

The above information is true and complete to the best of my knowledge. The Institute has my permission to obtain all necessary information from the references I have listed concerning my past experience and I release all parties from any possible damages resulting from disclosing such information with or without prior written notice from me. I understand that this application does not constitute a contract of any kind. Should the Institute enroll me, I may terminate such enrollment at any time, but understand that the Institute will retain all monies paid at the time of my approved enrollment.
I Agree With The Terms Above
I Disagree With The Terms Above

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