Name & Credentials (as you would like it to appear on your certificate)
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Names of Models/Patients (if any)
Full Name*
Education*
High School / GEDAssociate's DegreeDiploma / Professional DegreeBachelor's DegreeMaster's DegreeDoctorate Degree

Education & License Background* (please provide all details)
Do You Have Experience in a Clinical or Med-Spa Setting?* (include a timeline of work experience, responsibilities, and treatments performed)
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I am interested in:
BeginnerNeurotoxins - Level 1Dermal Fillers - Level 1Neurotoxins & Fillers - Level 1Lip Filler - Level 1Sculptra Butt-LiftManaging ComplicationsEthics for Medical Professionals
IntermediateNeurotoxins - Level 2Dermal Fillers - Level 2Neurotoxins & Fillers - Level 2

Eternite Medical Academy Private Training (*Any (Coming Soon) items should not be selected)Shadow Preceptorship (Coming Soon)In-Office Preceptorship (Coming Soon)
Contact Permission:*I agree to the Terms of Service and Privacy Policy provided by Éternité Medical Academy, LLC.
Marketing:*I agree to receive marketing messages from Éternité Medical Academy. I understand that I am agreeing to receive SMS and e-mail from Eternite Medical Academy.
Cancellation Policy:
Should a student’s enrollment be terminated or canceled for any reason, all refunds will be made according to the following refund schedule:

• Cancellation can be made in person, through electronic mail, through Certified Mail, or by termination.

• All monies will be refunded if the Academy does not accept the applicant or if the student cancels within three (3) business days after signing the enrollment agreement and making the initial payment.

• Cancellation after the third (3rd) business day but before the first class will result in a refund of all monies paid, except for the registration fee (not to exceed $150.00).

• Cancellation on the day of the class will result in no refund.

• Cancellation within 3 days before the class will result in a credit for future classes.

• Refunds will be made within 30 days of termination of the student’s enrollment or receipt of a Cancellation Notice from the student.

Grounds for Termination:

• I agree to comply with the rules and policies stated in the Academy Enrollment Agreement Form and understand that the Academy shall have the right to terminate this contract and my enrollment at any time for violating the rules and policies.

• I understand that the Academy reserves the right to amend the rules and regulations, and I will be notified of such changes.

Graduation Requirements:

• Students must complete all the hours required for each program.

• Students meeting the above requirements will be awarded a Certificate for their completion.

Career Services:
Éternité Medical Academy cannot guarantee employment for its graduates. However, the Academy’s curriculum has been developed to produce well-qualified graduates.
I acknowledge that I have read this agreement in its entirety and that I agree that I will receive a copy of the original contract in person and that all blank spaces have been completed to my satisfaction.I understand that when I write my name (or electronic signature), I recognize it as a valid electronic signature, and it will have the same legal effect as if I had done it personally.I agree to the Cancelation Policy of Éternité Medical Academy, LLC.

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