Academy for Five Element Acupuncture

APPLICATION FOR ADMISSION

Please have official transcripts and two (2) letters of recommendation sent directly to Admissions. You can email these to: admissions@acupuncturist.edu

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Qty

Description

Amount

Total

Application Fee

$150.00

Check all that apply

Master of Acupuncture

Chinese Herbal Studies

Desired Start Dates

Desired Start Month: *

Desired Start Year: *

APPLICATION INFORMATION

First Name: *

Last Name: *

Age:

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Home Phone: *

Work Phone:

Cell: *

E-mail: *

A receipt will be e-mailed to this address.

Birth Date:

(MM/DD/YYYY)

SSN:

Emergency Contact:

Emergency Contact #:

EDUCATIONAL BACKGROUND

Accredited College/University:

Dates Attended:

Area of Study:

Degree:

Date Received:

Accredited College/University:

Dates Attended:

Area of Study:

Degree:

Date Received:

Accredited College/University:

Dates Attended:

Area of Study:

Degree:

Date Received:

Describe any previous study of acupuncture:

PROFESSIONAL BACKGROUND
(from present to past)

Place of Employment:

Dates Employed:

Position/Title:

Place of Employment:

Dates Employed:

Position/Title:

Place of Employment:

Dates Employed:

Position/Title:

Present Occupation:

Professional License/Certificate:

Do you have any current professional license or certificate in the healing arts from a state agency?

Fields of Professional License/Certificate(s)

Referred by:

APPLICANT QUESTIONNAIRE

Why:

Why have you chosen to study at this school?

Plan:

How do you plan to make the time needed for home study (point location, pulses, etc.)? At least 20 hours per week is recommended.

Support:

Please describe how your family/home situation is supportive of and otherwise conducive to this course of study, especially your year of clinic residency in Florida during Year 3.

Transition:

If you are currently working, what plans do you have to transition to full-time study during the clinical year?

Vision:

What is your vision for your future acupuncture practice?

Finance:

How do you plan to finance your acupuncture education?

Current state:

Please describe your current state of health, physically and emotionally.

I have had acupuncture treatment with a Five Element practitioner.

I have not had acupuncture treatment with a Five Element practitioner.

I have not had acupuncture treatment.

If you haven't received acupuncture treatment with a Five Element practitioner, we encourage you to do so.

Your experience of acupuncture:

If you have had acupuncture, please describe your personal experience of what acupuncture treatment has been like for you.

Concerns or Questions:

Describe any concerns or questions you have about the school and/or your ability to complete all the requirements of the program.

DEMOGRAPHIC INFORMATION

Age:

Hispanic, Latino/a, or Spanish?

Your Racial Background (Select all that apply):

American Indian or Alaska Native

Asian

African American or Black

Native Hawaiian or Other Pacific Islander

White

Residency Status:

OTHER

In a separate email, please write a 300 word essay in response to the following questions: Why do you want to study acupuncture? Why are you interested in the Five Element tradition? Please submit your essay to: admissions@acupuncturist.edu

You must agree to each of the following:

I understand that my application will not be processed until my essay is received.

Your Payment Information

Name on Card:

Card Number:

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Expiration Date: