AC70 Returning Warrior Application | Helms Medical Institute

Medical Acupuncture for Physicians
Returning Warrior Application

Primary Course Units
Module One: 10-12 December 2021 (3 days; remote)
Module Two: 10-13 March 2022 (3.5 days; Tempe, AZ)
Module Three: 26-29 May 2022 (2.5 days; Tempe, AZ)

If you are a graduate of the basic MAFP course with a graduation date of September 2019 and later, you may select the clinical unit(s) you wish to attend. If you graduated prior to this date, you may be requested to register for all three live units due to evolving course curriculum. Contact HMI to discuss your situation and goals.

In addition to completing the application form below, the following items are required for your application to be considered. You must submit them via email to mafp@hmieducation.com:

Résumé / CV
Photocopy or scan of your current medical license
Statement of plans on on your interest in returning to the program and your use of acupuncture since first taking the HMI course
Documentation of COVID-19 vaccination (including booster)
Tuition payment

The fields indicated with an asterisk (*) are required.

Select the session(s) you wish to attend:*
Tuition is $2200 per session OR $6000 if payment for all three sessions is received by 10 November 2021.

Module One (10-12 December 2021 - REMOTE)Module Two (10-13 March 2022 - TEMPE, AZ)Modules Three (26-29 May 2022 - TEMPE, AZ)

First Name*

Initial

Preferred Name

Last Name*

Degree*

State Medical License Number*

Specialty*

Contact Information

Primary Email*

Home Address:

Street*

Street address only, no P.O. boxes.

City*

State*

Zip*

Primary Phone*

Please use the format 555-555-5555 for US phone numbers.

Secondary Phone

Please use the format 555-555-5555 for US phone numbers.

Year you completed the basic HMI course:

Indicate method of payment:*

CheckPreferred - Payable to Helms Medical Institute, 2520 Milvia Street, Berkeley, CA 94704Credit Card - by phoneCall 510-649-8488 between 9:00 AM and 2:00 PM Pacific Time or fax to 510-649-8692

Check the box below if you are a 2020-21 graduate eligible for special pricing. 2020-21 Graduate

All participants, HMI staff, and HMI preceptors must be fully vaccinated and boosted against COVID-19 to participate in in-person activities. Additional health and safety precautions may be implemented at the in-person teaching activities and these measures must be followed by all attendees.
For additional information about this course, call 510-649-8488 or e-mail mafp@hmieducation.com.