Application for ZBHA Certification Program

Page 1 of 5     ZBHA Certification Program Application       Contact Information:       1. First Name:*         2. Last Name:*         3. Email:*         4. I have signed into my ZBHA account (at the bottom of the home page) and the information in My Profile is correct.*   -- Please Select -- Yes No       5. I am enrolled in the ZB CorePak with IAHE*   -- Please Select -- Yes No         Professional Status: Identify yourself with one of the choices below and answer the questions that appear following your choice.       6. I am a licensed healthcare professional*   -- Please Select -- Yes No       7. I am a healthcare professional with no formal license and an active practice of three years or longer.*   -- Please Select -- Yes No       8. I am a healthcare professional with no formal license and an active practice of less than three years.*   -- Please Select -- Yes No       9. I am a student enrolled in a professional healthcare training program that leads to a license or certification.*   -- Please Select -- Yes No         Certification Program Agreements - Check indicates agreement with the statement below. You will receive a copy of these agreements.       10. Credentials: I understand that following receipt of an acceptance letter from the ZBHA, I may refer to myself in writing as a ZB Certification Candidate or a Candidate in the Zero Balancing Certification Program. Upon completion of the program, I may refer to myself as a Certified Zero Balancer.*   -- Please Select -- Agree Disagree       11. Licensure: It is my responsibility to maintain the legal right to be a healthcare provider according to the laws governing such practice in my state for the profession for which I hold a primary license or certification. If I do not hold a license or certification, I understand the Zero Balancing Certification does not confer a healthcare license.*   -- Please Select -- Agree Disagree       12. Program Fees: I agree to pay either the full program fee or all of my CorePak package prior to graduating from this program.*   -- Please Select -- Agree Disagree       13. I agree to complete all requirements of the program including attending at least 100 hours of approved classes, passing a written exam, passing a practical exam, and completing a program survey.*   -- Please Select -- Agree Disagree       14. Completion Time Period: I understand that the three-year term of this program begins on the date of acceptance and this expiration date is listed in my account profile. Prior to the expiration date, a one-year extension may be requested and if granted, obtained by paying $150 within two weeks of that expiration date. Failure to secure an extension before completing the program will result in being withdrawn.*   -- Please Select -- Agree Disagree       15. Ethics Guidelines: I have read and agree to the Ethics Guidelines of the ZBHA. * (Please copy and paste this link to view) https://www.zerobalancing.com/files/ZBHA%20Ethics%20Guidelines.pdf   -- Please Select -- Agree Disagree       16. Logos and Registered Trademarks: I understand the term Zero Balancing and the Fulcrum logo are both registered Trademarks held by the Zero Balancing Touch Foundation (ZBTF) and the use thereof, together with the term Zero Balancer, are reserved for those individuals who have officially graduated as Certified Zero Balancers and maintain the status of Certified Zero Balancer.*   -- Please Select -- Agree Disagree       17. Membership in the ZBHA and Maintaining Professional Certification Status: I understand that upon successful completion of this Certification Program, I will become a Certified Zero Balancer and a member of the ZBHA. Following an initial four-month complementary term, member benefits and Certified ZB Practitioner status are maintained by paying yearly dues.*   -- Please Select -- Agree Disagree