Application for Admission

CALIFORNIA COLLEGE OF AYURVEDA

Application for Admission

Personal Information

Name (Last) ____________________________ (First) _____________________ (MI) ____

Other name(s) which may appear on documentation ________________________________

Mailing Address _______________________________________________________________

City ____________________________________ State ____________________ Zip _____

Telephone (day) ______ - ______ - ________ (eve) ______ - ______ - __________

S.S.# _______________________ Email address __________________________

U.S. Citizen/Permanent Resident __Yes __ No If no, please complete the next line:

Country of Citizenship ________________ Visa Type __________ Issue Date __________

Current Occupation: ___________________________ Employer _____________________

Emergency Contact : Name _____________________________________________________

Telephone (day) ______ - ______ - _________ (eve) ______ - ______ - _________

Where I heard about CCA: ______________________________________________________

Educational information

Do you have a high school diploma or equivalency? ____ Yes ____ No

Regardless of whether you earned a degree, please list all post-secondary schools

which you have attended.

Name/Address Degree Dates Attended

______________________________________________________________________________

Please list additional professional training you have received.

Name/Address Type of Training Dates Attended

______________________________________________________________________________

Application for Admission

Hobbies/Interests

_____________________________________________________________________________

My first choice is to enroll in the _______________ class.

My second choice is to enroll in the ________________ class.

I am interested in:

___ A.H.E. Program (Ayurvedic Health Educator)

___ A.H.P. Program (Ayurvedic Health Practitioner)

___ C.A.S. Program (Clinical Ayurvedic Specialist)

___ A.H.E. and A.H.P. Programs Combined

___ A.H.E., A.H.P. and C.A.S. Programs Combined

___ I'm not yet sure.

I affirm that the information I have provided is accurate to the best of my knowledge.

Signature ________________________________________ Date ______________

Note: Before final acceptance into our program, all students will have the opportunity to speak (by phone or in-person) with CCA founder Dr. Marc Halpern or an enrollment counselor who will discuss your needs and answer any questions that you may have. We will contact you as soon as we receive your application to schedule an appointment.

Please answer the following questions about your contact with us:

Have you ever attended a talk or workshop by Dr. Marc Halpern? Yes ___ No ___

Have you had a phone consultation or personal tour of CCA with Dr. Halpern?

Yes ___ No ___

Have you visited the California College of Ayurveda and had a tour with someone else?

Yes ___ No ___

Occasionally we make our mailing lists available to other organizations that offer a related product or service that may be of interest. If you do not want to receive these mailings, please initial here:

__________

Please mail your completed application with a $55 non-refundable application fee to the California College of Ayurveda, 1117A East Main St. , Grass Valley , CA 95945 .

Revised 4/25/06