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Wellness Counselor and Certification Program

Application for Admission

Name (Mr. Miss Ms Mrs.):

 

Address:

 

City:

 

State: Zip:

Phone (home):

 

(work):

(cell):

 

(fax):

Email:

 

Occupation:

 

Company:

Age:
Marital Status:

 

How Long Married?:
Children?:

Where were you born and/or raised?:

 

What is your native language?:

 

Religous upbringing and preference now:

 

Any serious accidents or illness?:

 

What?:
When?:

Are you under a doctor's care?:
Yes No

 

What are you under a doctor's care for?:

Are you taking any medications?:

For what?:

Spare time activities:

 

High school you graduated from:

City and State of high school:

OR, date and place high school equivalency exam was taken:

Have you ever seen a counselor?:

For what?:

* Write a short essay describing your life, the adversities you have overcome and how you overcame them. Include how you envision using these counseling skills and with whom? Please Check One:
I am applying for Wellness Counselor Training on Sundays only.
I am applying for both the Wellness Counselor Training on Sundays and the Professional Business Development course on Wednesday.

I am applying for the Professional Business Development course on Wednesday only.

I am applying online and would like to pay the $100 application fee by credit card.

TOTAL:

Credit Card:

  

CC#
Expiration Date (XX/XX):

 

If paying by check, print out form, fill in your information and send with application fee of $100 to:
The Hawaii Wellness Institute, 3670 Kalihi Street, Honolulu, HI 96819

The statements on this application are true. I understand that if I qualify for admission, I will be expected to attend every class, to give practice sessions weekly, and to pass a written exam in order to obtain certification as a wellness counselor.

Date________________ Signature__________________________________________________


The Hawaii Wellness Institute does not discriminate on the basis of race, color, national origin, sex, religion, age or disability.


* Applying by mail: Attach typewritten essay describing your life, the adversities you have overcome and how you overcame them. Include in this essay how you envision using these counseling skills and with whom?


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