Astym Certification: In-Person Course Registration

The course registration below should only be completed by the individual who will be attending the course.

If you are not the student, we kindly ask that you do not fill out the registration on behalf of the student. This ensures all information is accurately recorded and the student receives all necessary course materials and communications directly.

YOUR INFORMATION

Name(Required)

First Last

Fill out how you want your name & professional designation to appear on your certificate:(Required)

Work Email(Required)

Personal Email(Required)

Cell Phone(Required)

Which email would you prefer us to use for communications?(Required)

Work Email

Personal Email

License Number(Required)

List specialties and/or advanced training

YOUR CLINIC INFORMATION

Please provide the details of the clinic where you’re currently providing. When you’re officially Astym Certified, we’ll list your clinic on our Find a Provider page so patients in your area can easily locate you!

Clinic Name(Required)

Clinic Address(Required)

Street Address Address Line 2 City State ZIP Code

ACKNOWLEDGEMENT AGREEMENT

Acknowledgement Agreement(Required)

As a condition to my participating in and receiving the training program in the performance of Astym® treatment provided by Performance Dynamics, Inc., an Indiana Corporation (“PDI”), I acknowledge and agree to the following:

1. PDI owns all rights in and to Astym treatment and all materials pertaining to the Astym treatment, including, but not limited to, all methods and elements of Astym treatment, instruments, written materials, manuals, clinical instruction, trade secrets, trade and service marks, patents, copyrights, outcome and other software, and other materials pertaining to Astym treatment (collectively, the “Materials”). Any research, modifications or improvements that I may make or contribute to pertaining to Astym treatment or the Materials shall be the sole property of PDI.

2. Materials pertaining to Astym treatment provided to me by PDI, either at the time of my training or after, in whatever form or medium, tangible or intangible, are not mine, and PDI shall continue to hold the exclusive rights to, and ownership of, such materials.

3. I will only use the Materials as provided in the agreements entered into between my employer/clinic and PDI, and I agree to be bound by the terms of those agreements. I shall keep all clinical instruction regarding Astym treatment confidential, and only use the Materials in the treatment of my patients, and not for any other purpose. No video or audio recording of such clinical instruction is permitted. I shall stop performing Astym treatment and return all Materials to PDI if I leave my current employment/clinic or the Service Agreement between my current employer and PDI is terminated for any reason. I may resume providing Astym treatment under another Service Agreement.

4. In granting certification, I understand that PDI grants me permission to perform Astym treatment in the areas of application and in the manner set forth in the training course to be applied as determined by my clinical judgment. PDI does not promote, suggest or approve of any other applications, nor does it determine my scope of practice, which is to be determined solely by me in accordance with all applicable standards, rules and regulations. I will not perform Astym treatment unless I am trained and certified by PDI, and under an active Service Agreement with PDI.

5. The Astym treatment process is a trade secret of PDI, and I shall keep the process strictly confidential and only use it in the treatment of my patients. I will keep confidential all Materials and instruction provided by PDI. I will only perform Astym treatment or any element thereof if I am authorized to do so under an agreement with PDI. I will not train, instruct or advise anyone in the performance or use of the Astym treatment or instrument assisted soft tissue mobilization.

I have read and agree to the Acknowledgement Agreement, and confirm I am the student registering for this Astym Certification course.

Signature(Required)

Does your clinic need a set of Astym Instruments?(Required)

A standard set of instruments is $995. If elected, you will receive your instruments at the course on behalf of your employer.

Yes

No, my clinic already has instruments which I will share with other Astym Certified providers

We supply training sets of Astym instruments to be utilized during the course, therefore you do not need to bring instruments to the course. Once registered, you’ll be able to review any requirements and expectations for attending the Astym Certification course in the Provider Resource Center.

YOUR COURSE

Do you have any medical or physical condition that will keep you from being treated with the Astym treatment during class?(Required)

Yes

If yes, please explain:(Required)

Astym Certification: In-Person Course Registration

YOUR INFORMATION

YOUR CLINIC INFORMATION

ACKNOWLEDGEMENT AGREEMENT

YOUR COURSE

SUBMIT REGISTRATION