Print
this form
Tamalpais Relational Energy Healing Program
Registration
Form for 2006 Academic Year
|
|
| Date: |
|
__________
|
| Please
attach recent photo here: |
| |
|
|
Name |
|
____________________________________________________________ |
Address |
|
____________________________________________________________ |
| |
|
____________________________________________________________ |
Phone
# |
|
____________________________________________________________ |
E-mail |
|
____________________________________________________________ |
Occupation |
|
____________________________________________________________ |
| Age
(optional) |
|
______________ |
| Emergency
Contact |
|
___________________________________________________ |
| Phone
# |
|
___________________________________________________ |
Address |
|
___________________________________________________ |
| |
|
|
| |
Previous
workshops, training programs and degrees
related to psychology and/or energy healing
(please include schools, and date of graduation
or certification): |
|
| |
____________________________________________________________ |
|
| |
____________________________________________________________ |
|
| |
____________________________________________________________ |
|
| |
|
|
| |
Please
describe how you approach personal growth
(therapy, meditation, shamanic journeying,
healing work, etc..) |
|
| |
____________________________________________________________ |
|
| |
____________________________________________________________ |
|
| |
____________________________________________________________ |
|
| |
|
|
| |
What
draws you to this course of study at this
time? |
|
| |
____________________________________________________________ |
|
| |
____________________________________________________________ |
|
| |
____________________________________________________________ |
|
| |
|
|
| |
What
are your goals for attending the training? |
|
| |
____________________________________________________________ |
|
| |
____________________________________________________________ |
|
| |
____________________________________________________________ |
|
| |
|
|
| |
List
present physical condition, any challenges
you are having and specific needs you may
have in a learning atmosphere. |
|
| |
____________________________________________________________ |
|
| |
____________________________________________________________ |
|
| |
____________________________________________________________ |
|
| |
|
|
| |
List
current medications you are taking: |
|
| |
____________________________________________________________ |
|
| |
____________________________________________________________ |
|
| |
____________________________________________________________ |
|
| |
|
|
| |
Are
you interested in finding a roommate for
each class? __YES __ NO |
|
| |
|
|
| |
Upon
acceptance, you will be sent an informed
consent/release form to sign and return. |
|
| |
|
|