Student Application

application for the Experiential Polarity program

Note: Please read the Requirements for Admission and Code of Conduct from the Student Handbook and prior to submitting your application.

Name *
Phone Number *
Phone Number
Emergency Contact Phone Number *
Emergency Contact Phone Number
List any past medical or psychological conditions, including injuries and hospitalizations:
List any medications, nutritional supplements, herbs, and vitamins you are taking.
Are you currently under treatment with a Doctor, Chiropractor, Osteopath, Naturopath, Bodyworker, Acupuncturist, Polarity Practitioner, or other Health Care Practitioner? If so, please explain:
Why are you interested in taking this program?
Are there any special conditions that might affect your ability to complete your training or would require special treatment during the program? If so, please explain:
List/describe any complementary and alternative training you may have, or courses you have taken.
What is your educational background? Please list your traditional experience and levels completed, i.e. high school, college, graduate school, post-graduate, professional, vocational trainings, etc.
I Agree to the Terms & Conditions *

Do you have questions about the Polarity Therapy Training Programs?

For more information on Polarity Therapy or our Training Program, get in touch with Dr. Fazio.