Advancing Aesthetics SkinPen Microneedling Training Intake Advancing Aesthetics SkinPen Microneedling Training Intake Form Step 1 of 3 33% PART 1 – STUDENT INTAKE FORM Advancing Aesthetics – SkinPen Microneedling Training Hosted by Aspen Medical AestheticsYour Full Legal Name First Last Your Email Address Enter Email Confirm Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Your PhoneEmergency Contact Name Emergency Contact Phone Professional InformationLicense Type: Aesthetician Advanced Aesthetician Cosmetologist RN / Medical Professional Student (pending graduation) License Information License Number:State of License:Expiration Date: Add RemovePlease attach a copy of your license or proof of enrollment/graduation.Max. file size: 512 MB.MEDICAL & SAFETY SCREENING (for hands-on participation)Allergies (latex, topical products, lidocaine, etc.): Skin sensitivities or medical conditions relevant to microneedling: Have you ever fainted during medical procedures? Yes No Are you pregnant or breastfeeding? Yes No Do you have any condition that would prevent participation as a model? Yes No If yes, please explain: COURSE EXPECTATIONS ACKNOWLEDGMENTI understand this is a professional medical aesthetics training. I understand participation requires professionalism and respect. I confirm the information above is accurate. I understand and agree to the above statements. PART 2 – STUDENT CONSENT & TRAINING AGREEMENTADVANCING AESTHETICS – STUDENT CONSENT, CONFIDENTIALITY & LIABILITY AGREEMENT. Please read carefully and acknowledge each section by checking the box.COURSE EXPECTATIONS ACKNOWLEDGMENT2. ASSUMPTION OF RISK I understand microneedling is a medical aesthetics procedure and that participation as a student or model may involve: • Skin redness or irritation • Sensitivity • Minor pinpoint bleeding • Temporary swelling • Other normal post-treatment effects I release Aspen Medical Aesthetics, Advancing Aesthetics, instructors, and staff from any liability related to my voluntary participation. I understand and agree to the above statements.ASSUMPTION OF RISKI understand microneedling is a medical aesthetics procedure and that participation as a student or model may involve: • Skin redness or irritation • Sensitivity • Minor pinpoint bleeding • Temporary swelling • Other normal post-treatment effects I release Aspen Medical Aesthetics, Advancing Aesthetics, instructors, and staff from any liability related to my voluntary participation. I understand and agree to the above statements.NO REFUND POLICYI understand and agree that: • All course fees are NON-REFUNDABLE • No refunds will be issued for cancellations, no-shows, illness, travel issues, or scheduling conflicts • Transfers are at the sole discretion of Advancing Aesthetics I understand and agree to the above statements.INTELLECTUAL PROPERTY & NON-DISCLOSUREI acknowledge that all materials presented in this course are the exclusive property of: • Advancing Aesthetics • Aspen Medical Aesthetics • Course instructors This includes but is not limited to: • Protocols • Training methods • Written materials • Demonstrations • Business practices • Treatment techniques I agree: • NOT to copy, reproduce, or distribute any course materials • NOT to teach this proprietary content as my own • NOT to share protocols with other training programs • NOT to record, screenshot, or duplicate materials I understand and agree to the above statements.NO PHOTOS / NO VIDEO POLICYI understand and agree that: • NO photos are permitted during theory • NO video recording is permitted at any time • NO audio recording is permitted • NO filming of models or procedures Violation will result in: • Immediate dismissal • Forfeiture of certification • Removal from premises I understand and agree to the above statements.PROFESSIONAL CONDUCTI agree to: • Act professionally at all times • Respect models and classmates • Follow instructor direction • Maintain a clean, safe environment • Refrain from disruptive behavior Aspen Medical Aesthetics reserves the right to dismiss any student for unprofessional conduct without refund. I understand and agree to the above statements.CERTIFICATION DISCLAIMERI understand that completion of this course: • Does NOT guarantee employment • Does NOT replace state licensure • Does NOT permit practice outside my legal scope • Requires adherence to my state regulations I understand and agree to the above statements.LIABILITY RELEASEI hereby release and hold harmless: • Aspen Medical Aesthetics • Advancing Aesthetics • Instructors • Staff • Medical director from any claims, damages, or injury arising from participation in this course. I understand and agree to the above statements.LIABILITY RELEASEI hereby release and hold harmless: • Aspen Medical Aesthetics • Advancing Aesthetics • Instructors • Staff • Medical director from any claims, damages, or injury arising from participation in this course. I understand and agree to the above statements.MEDIA RELEASE (OPTIONAL) I consent to photos of me being used for educational marketing I DO NOT consent PAYMENTIn order to complete your registration, call Aspen Medispa (262) 241-2273 to pay the tuition fee of $1200. I understand my spot is not confirmed until I call Aspen Medispa (262) 241-2273 to submit my payment. Digital SignatureI have read, understand, and agree to all terms. First Last
