Name:

Date of Birth:

Address:

City:

State:

Zip:

Country:

Email Address:

Telephone Number (Day):

Telephone Number (Evening)

Gender

Degrees or Certifications

1

2

3

What is your Current Occupation?

Additional Studies related to Holistic/ Alternative Healing?

What do you expect to learn while in the program?

How do you plan to use what you will learn?

How did you hear about us?

Financial Information

Tuition is expected to be paid in full or in an approved installment plan prior to first class.  Acceptance into the program is based upon the date of the receipt of a  complete application package.  Once the maximum number of applications has been received, subsequent applications will be placed on a waiting list.

Installment Plan

I am interested in Installment Plan (Please call our office for customized Payment Plans)

I am NOT planning for Installments, I will pay the fees in FULL

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