Training Application | Peggy Reynolds

Name*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Date of Birth*

Occupation and years*

How did you hear about this training?*

For which training are you applying?*

Are you interested in the two year training?*

Summarize your health education experience and specify profession training

Summarize your experience as a professional in the health field*

Please describe your health condition and medical history, including any current medications*

Do you receive therapy? With whom?*

Any other relevant information?*

Any other information you would like Peggy to know that would support your application*

We require a $300.00 non refundable deposit with application. Deposit deadline is two weeks before the course. Are you ready to commit to this and the additional $450.00 due the day before the training?

Please make your purchase on paypal here.

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