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A.I.M. REGISTRATION FORM

PROSPECTIVE STUDENT RELEASE OF INFORMATION FORM

The student release is required should there be inquiries from the State Board of Nursing or the Individual to confirm attendance and completion of the course.


PLEASE PRINT

I do / do not authorize Acupuncture and Integrative Medicine Institute (AIMI) to release information in my student file to State Board of Nursing to verify my completion of the Acupuncture Certification Program.: I may revoke this authorization at any time, provided that I do so in writing and submit it to the party listed above. The revocation will take effect when received..

PARTICIPANT AGREEMENT

PLEASE PRINT

1. Information contained in the course curriculum may not be used by the undersigned (participant) in connection with all commercial activities or activities of a non-professional nature which include but not limited to any distribution or promotion of products and services used in the course.

2. During the course practicums participants will be required to be subjected to acupuncture therapy and expose particular body surface areas so that others participants can train in the procedure. Your signature below implies informed consent and that you are aware of the acupuncture risk which include: local bleeding, pain, bruising and infection) although clean needle technique will be used throughout to the course to avoid these risk and participants will be supervised by a Licensed Acupuncturist to insure proper technique and safe practice. If you do not agree to participate in practicums, you will not be qualified for certification.

3. AIMI reserves the right to dis-enroll any participant who displays disruptive behavior, is disrespectful of the participants or instructors, and/or violates patient confidentiality/HIPPA, with forfeiture of tuition.

4. Tuition Reimbursement: Tuition is non-refundable after the start of the program. Tuition paid prior to the start of the program will be refunded on request minus the pay gate service fee if a student wishes to withdraw prior to the start of the course.

5. Participants must also agree to inform the instructor or any AIMI staff, if they have acquired or been diagnosed with a communicable disease that may place others at risk (to include past medical history of hepatitis, HIV, etc.) to ensure proper precautions are taken prior to the practicums.

6. AIMI will insure that all participants are respected and should any participant feel any level of discomfort or conflict during the program, regardless of the nature or individual it will be addressed immediately by the director.

I certify that I have read the above agreement, understand the contents and requirements of the course and consent to full participation: