Applicant Information
Your Name (required)
Date of Birth (required)
Your Email (required)
Phone # (required)

Applicant Address
Address Number
Street
City
State
Zip Code

Danzan Ryu Restorative Therapy Program Information
Program Director’s Name (Person teaching the program):
Program Director's Email: (required)
Location of Program:
Start Date:
This program will be taken (Choose one):
In-personOnline Blended

Will you be applying for a Professor Pat Browne DZRRT Scholarship?
YesNo

AJJF Information
Are you studying jujitsu?YesNo
AJJF# (required)
AJJF Rank

Your Sensei or DZRSI Instructor
Your AJJF Dojo or DZRSI Program

Applicant's DZRRT Program History
I have graduated from a Danzan Ryu Restorative Therapy (DZRRT)
Program and have received a certificate for:
DZRRT Technician Graduation Date
Program Director Name
Program Location

DZRRT Practitioner Graduation Date
Program Director Name
Program Location

Other Healing Arts Training, please list:


Have you ever spoken to any instructor of DZRRT about taking this course?
YesNo

If yes, to whom have you spoken?

Sign the Agreement

“I understand that to enter this course, I will be required to:

*Be an AJJF Registrant and to maintain my Registration for the duration of the program

*I understand that the AJJF Registration fee is non-refundable
* Complete an AJJF background Screen and maintain a Clear Status for the duration of the program
* I understand that the AJJF Background Screen fee is non-refundable
* Pay all course fees
*Sign the DZRSI Ethics Statement (This is different from the AJJF Black Belt Ethics Statement)
*Be at least 18 years of age of older
*Practice will involve physically giving and receiving bodywork in the course
*Have a High School diploma, or GED, or demonstrate an ability to benefit from the course.
*Have computer skills, or assistance as required, sufficient for the course work
*Pass an interview on those skills with my Online Manager, if any portion of the course is online

“I understand the above, and agree to each of the items listed.
“Before and during the course, I will inform the Program Director of any personal health concerns relevant to the giving and receiving of bodywork. I understand that the information I share will be confidential.
“My signature physically or electronically affirms my agreement to all of the terms above, my promise that all information provided is accurate to the best of my knowledge and that my intention is to participate in this program and to successfully complete all of the coursework.”

Student's Signature

Date

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