Training Application Name*Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Date of Birth* Date Format: MM slash DD slash YYYY 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 trainingSummarize 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. CAPTCHA