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Date:

  

Name:

  

Address:

  

City:

                                                        State:          Zip:             Country:

Phone:

  

Sex:

[   ] Male    [   ] Female                 Age:

Indicate the course series for which this application is being requested:
                  [   ] 2002 Course Series        [   ] 2003 Course Series

List all the colleges that you have attended in the order of earliest to the most recent:

Name of College
 City/State
 Dates Attended
 Major/Degree
 Grad. Date
          
          
         
         

Have you ever been dismissed from a college, graduate, or professional school?
[   ] Yes  [  ] No   (If "yes", explain the circumstances on a separate sheet of paper)

The following guidelines for admission to this course must be agreed to and initialed by the applicant:

1. I have not been convicted of a felony. Initialed:           

2. I have a high school level minimum education. Initialed:           

3. I have not previously held any form of health care credential that has been revoked or currently suspended for any cause. Initialed:           

4. Before I enroll in this course, I will secure a doctor (or Ph.D.) who is licensed to diagnose, and is board certified in clinical thermographic analysis (with extended training in infrared breast imaging) by a reputable agency, to interpret and provide reports to members of the general public being screened by me. I also agree to notify the I.A.C.T. immediately if any change is made to another doctor for interpretive services. Initialed:           

5. I agree to uphold the by-laws of the I.A.C.T., all protocols set forth by the I.A.C.T., and to any disciplinary action (up to and including immediate termination of reading services and potential revocation of certification) being necessary by the Board of Directors of the I.A.C.T. in order to maintain high quality standards and protection of the public. Initialed:           

6. I will maintain the highest quality control of my laboratory and/or insure the environmental controls of any facility wherein I may perform thermographic evaluations and further consent to allow officials of the I.A.C.T. to make spot inspections of said facilities to insure quality control. I also agree that all said facilities must also be monitored and supervised by a board certified clinical thermographer. Initialed:          

7. I agree not to perform thermography in violation of any of the above codicils nor without direct management by a doctor (or Ph.D.) who is licensed to diagnose and board certified in clinical thermographic analysis (with extended training in infrared breast imaging) by a reputable agency. Initialed:           

8. It is my responsibility to insure that the terms of this order are not in violation of state law or other judicial notices local or otherwise which may preclude me from performing the role of a thermographic technician. I also understand that as a person contemplating a career as a clinical thermographic technician it is in my best interest to consult with legal representation to insure that no such violation of law will effect in any way my ability to successfully perform thermographic laboratory services. Initialed:          

With regard to article #4 above, you must provide proof that a qualified interpreter has been secured before the first scheduled class. The following will need to be provided by the applicant and mailed to the I.A.C.T. prior to beginning the course (please give ample time for us to verify the accuracy of the documentation):

  • The doctor’s name, address, and phone number
  • A copy of his or her current state license
  • A copy of his or her thermographic certification document(s)
  • Name and phone number of the certifying agency
  • Information on the doctor’s extended training in breast thermography

Please make checks or money order out to IACT and mail the completed application and items above to:

International Academy of Clinical Thermology
C/O Secretary/Treasurer 
Robert L. Kane, DC, DABCT, DIACT(B), FIACT
621 Middlefield Road
Redwood City, CA. 94063

Application Certification

I certify that all the information presented in this course application is correct and accurate. If accepted, I agree to abide by all the rules and regulations in effect during my enrollment in this course.

Signature of Applicant:                                                  Date:                     

Reservation of Rights and Notice of Non-Discrimination
The International Academy of Clinical Thermology (IACT) reserves the right, without notice, to modify the requirements for admission; to change the arrangements or content of the modules/course, the instruction materials used, the tuition; to cancel any module or course at any time; to alter any regulation affecting an attendee; to refuse admission to any person at any time, or to dismiss any person from the course at any time, should it be in the interest of the IACT or the attendee to do so. The IACT does not discriminate on the basis of race, color, sex, national origin, age or handicap in the process of admission. Having read and fully understanding all of the information enclosed, I the undersigned agree to all the stipulations as outlined in this admissions packet.

Signature of Applicant:                                                  Date: