Clinical Externship Application Form

Part 1: Contact Info

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Emergency Contact(Required)

Which session are you applying for(Required)

Part 2: Prior Clinical Experience/ Training

Are you currently enrolled in a herbal medicine training program? Which one and how many hours have you completed?

Have you observed patient intakes in a herbal medicine clinic?

Yes

Have you conducted patient intakes in a herbal medicine clinic?

Yes

Part 3: Food and accommodation

On-site camping is available from MAY - SEPTEMBER at a cost of $35/ night. Campers must provide their own tents and bedding.

Are you planning to camp at Innisfree Farm?

Yes

No, I will find accommodations elsewhere

Dietary Restrictions:

gluten free

dairy free

Vegetarian

Vegan

Other serious food allergies?

Part 4: Medical Conditions

Do you have any serious/ life-threatening medical conditions (e.g. allergies, seizures, asthma etc)?

Part 5. Program Fees

$624.65 CAD (+GST)

**For international students - if we are billing your institution directly, you will need to cover the Canadian taxes (5% of program fees)

Cancellation Policy: To ensure a rich and personalized experience, we limit the program to a small group of students. As a result, we are unable to provide refunds if you cancel after your fees have been paid.

Waiver and disclaimer

1. Students understand and agree that nothing taught in this program gives them permission or license to practice medicine. Material is presented for educational purposes only.

2. Students understand and agree that neither the instructors, Katolen Yardley and Chanchal Cabrera, nor the location (Innisfree Fam) can or will be held liable or responsible for how the student uses and applies the knowledge gained in this program.

3. Program fees are non-refundable once paid

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