Diploma inIyisana Reflex Therapy |
Application Form |
Please print off this page, complete the form and send it, along with your deposit cheque, to the address at the bottom of the page.
Name..………………………………………………………..………............................................................................... (Please state your full Christian name and surname, plus the name you wish to be known by) Address.……………………………….......………………………….............................................................………….. …………………………………………………….……………………….................................................................………… …………….......……………………….........................................……Postcode………….…………………………….. Tel No ………...……………........................…... Mobile................................................................................... Date of Birth …....……….......……… Occupation ….…………….................………………………………….. Email Address..……………………………………………………........................................................…………….. Details of any relevant qualifications or experience ...............................................................…………………………………....................................................................... …………………………………………………......……………………………........................................................................ ………………………………………………………..........……………………….................................................................... During the course you will be acting as a client for fellow students. Please let me know of any health issues I need to be aware of: …………………………………………………………….......……………….......................................................................... ……………………………………………………………….................................................................................................. ………………………………………………………............................................................................................................ ……………………..………………………………………................................................................................................... Please indicate whether you have any disabilities/learning difficulties ……………………………………….……...…….......................................................................……................................. …………………………………………………..………...................................................................................................... Please give your reasons for wishing to train as a reflex therapist ………………………………………….………….............................................................................................................. ……………..………………………………………............................................................................................................ ……………………………..……………………………….................................................................................................. ………………..………………………………................................................................................................................... I enclose a deposit of £100.00 and will pay the balance as follows:
(Please cross out the line which is not applicable)
Signature ………………………………………...………...........................…….. Date ……...............................................................………........…….………… (Cheques to be made payable to Anne Thomas please) Please return your completed application form to the address below:
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