Therapeutic Horticulture Practitioner Application

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Horticultural Therapy
(9 semester credits required)

All applicants must successfully meet the work experience criteria as identified in Section III of the AHTA Professional Registration Policies and Procedures, and complete the THP Verification of Work Experience Document

First Name *

Last Name *

Prior Name

If your transcripts are under a different name, please list below(Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change:

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

Phone 1

I certify that all the information given in this application is true and correct to the best of my knowledge. I further understand that false representation relative to any information will provide the basis for permanent disqualificatio for participation

Electronic Signature of Applicant: *

Date: *

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College or University (1) *

If entering multiple courses from the same college/university, please list all corresponding information (Course Title, Semester Credits, AHTA Topic Area) together in the single box relative to their section.

Course Title *

Semester Credits: *

AHTA Topic Area *

College /University (2)

Course Title:

Semester Credits:

AHTA Topic Area(1)

College or University (3)

Course Title

Semester Credits:

AHTA Topic Area:

College/University(4)

Course Title

Semester Credit(4)

AHTA Topic(4)

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I am submitting(THP documents) *

Work Experience Documentation *

Additional Document 1

Additional Document 2

Facility/Organization *

Address/City/State/Zip/County *

Applicant Position: *

Name of Work Contact: *

Business Phone: *

Work Contact Email: *

Work Contact Position: *

Is the Work Contact professionally registered with AHTA? *

Yes

If Yes, Professional Registration Status? *

Hours of Direct Client Services *

Hours of Non-Direct Client Services: *

Hours of Horticulture Client Services: *

Total number of hours: *

Dates (from, to): *

C. Academic Transcripts

List below those academic institutions forwarding official transcripts to the AHTA National Office.

Institution (1) *

Institution (2)

Institution (3)

Institution (4)

Institution (5)

Institution (6)

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