Professional Training Program Application
(You can also open and print our complete information packet and application form in Acrobat PDF.)

GESTALT INSTITUTE OF THE ROCKIES

Professional Training Program

800 Washington Ave., Unit D, Golden, CO 80403

(303) 426-8211 FAX (303) 429-9512 (303) 985-3534

www.gestaltoftherockies.com

 
 Student Application
(Please print legibly)
 
 

Name of Applicant

 

Date of Application

 

Date of Birth:

 

Gender:

    M        F        (Please Circle)

 

Street Address

 

City, State, Zip

 

 

Phone Number (s)

 

Fax:  

 

E-Mail:

 

 

To which training program are you applying? (Please Circle)                

 

Basic        Advanced

 

 

 1.  Autobiography:

 Please attach an autobiography (2 to 4 pages) including information about yourself and your interest in Gestalt Therapy training.

 

2.  Degrees Held:

Year

Institution

Degree

Major Field Of Study

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.  Previous Post-Graduate or special training experience(s): (NLT, Gestalt, Sensitivity Training, Tavistock, etc.)

Year

Length of Time

Name of Program

Leader(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

4.  Why did you select Gestalt Institute of the Rockies?

 

 

 

 

5.  List three references who know you and your work:

#1 Name:

 

Profession:

 

Street/City/ State/ Zip:

 

Phone:

 

 

#2 Name:

 

Profession:

 

Street/City/State/Zip:

 

Phone:

 

 

#3 Name:

 

Profession:

 

Street/City/State/Zip:

 

Phone:

 

 

 

 

6. Professional work experience (your present position):

Organization:

 

Date employed:

 

Street/City/State/ Zip:

 

Phone:

 

Responsibilities:

 

Immediate Supervisor:

 

Supervision:

 

 

 

The above information is true and complete to the best of my knowledge.  The Institute has my permission to obtain all necessary information from the references I have listed concerning my past experience and I release all parties from any possible damages resulting from disclosing such information with or without prior written notice from me.  I understand that this application does not constitute a contract of any kind.  Should the Institute enroll me, I may terminate such enrollment at any time, but understand that the Institute will retain all monies paid at the time of my approved enrollment.

 

 

Applicant’s Signature:

Date:

 

 

GIR Representative:

Date: