SCHEDULE : REGISTRATION

Wednesday, March 10, 2010

Contact Information

Name *

Address *

City *

State or Province*

Zip or Postal Code *

Day Phone *

Night Phone

Fax

eMail Address *

Emergency Contact Name *

Emergency Contact Phone *

How did you hear about our program? *

Medical Information

Are there any important and/or severe medical conditions that we should be aware of? Please describe each condition where applicable.

Muscular/Skeletal

Mobility Problems

Heart Conditions

Psychological History

Severe Allergy(ies)

Diabetes

Are you currently under a doctor's supervision for any reason? Please list below.

Do you need permission from your doctor to attend this training? *
Please select… Yes No

Personal Information

What is motivating you to join this training program and what do you want to gain from this experience? *

Share a brief history of your experience in the field of movement, creative expression and personal growth work. *

What limits/challenges do you bring to the training? What gifts/strengths do you bring to the training? *

Security

Type the characters you see above into the box below.