Medical Qigong Practitioner

Name *

First Name

Last Name

Phone *

Country

(###)

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Of Birth *

MM

DD

YYYY

Emergency Contact Phone *

Country

(###)

###

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Are You Licensed To Practice Medicine (Or Any Healthcare Based Modality)? *

Yes

No

If "Yes" To Previous: Is Your License Active And In Good Standing?

Yes

No

Has Any Agency Or Association Ever Investigated Or Taken Action Against You Personally And/Or Your Professional License? *

Yes

No

Not Applicable

Do You Have Any Medical Conditions, Physical Limitations, Or Health Concerns That May Effect Your Ability To Participate In The MQP courses? *

*Answers to these questions do not affect program entrance eligibility, and are asked only to best meet the needs of accepted applicants. Your application and its contents are kept confidential in accordance with our privacy and health records policies.

Yes

No

Have You Ever Been Convicted Of Any Criminal Activity (Minor Traffic Violations Excluded)? *

Answers to these questions do not necessarily affect program entrance eligibility.

Yes

No

Your Application Will Be Reviewed ONLY Once Your Deposit Has Been Received. *

I understand that upon submission I will be redirected to a secure payment portal to make a tuition deposit ($1200). I understand that my application will NOT be reviewed until a tuition deposit is received. Upon acceptance to the program, your deposit becomes non-refundable. Should you not be accepted, OR you decline enrollment (AT THE TIME OF YOUR INTERVIEW) your deposit will be refunded.* This deposit guarantees your space in the program. Applications received without a tuition deposit will be automatically deleted from our records after 72 hours (at which point, to be considered for program admittance you will need to resubmit an application--with deposit--to reestablish placement in the admissions process queue).

Consent To Receive Electronic Communication *

I understand that submission of this form constitutes agreement to receive electronic communications (email list inclusion). While necessary to process your application continued inclusion is voluntary (you may unsubscribe at any time).

STATEMENT OF ACKNOWLEDGEMENT* *

I have read, understand, and agree to the terms of service and conditions of enrollment set forth by Red Thread Institute. I attest that all information I have provided herein is complete, accurate, and truthful. I understand that agreeing to this statement constitutes an electronic signature.