Mindful Shiatsu Center
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Online Registration Form

Class you are registering for:

Student Information
Name:
Address:
City: State: Zip code:
Phone: H W C
Email:
Occupation:
Status: Private Practice    Employed    Full time    Part time
If Part time, your other occupation:

Professional Schools Attended
School: Dates:
School: Dates:
School: Dates:
Are you in a program currently: Yes    No
If yes, where:

Licenses/Certifications Held
State: License/Certification:
State: License/Certification:
State: License/Certification:

Reasons for taking this class / what you hope to learn in class:

Registration Deposit and Cancellation Policies
Advanced class registration is required with a 25% deposit. A two week notification of cancellation is required for full refund of registration deposit.

After submitting this form, you will be given the option to pay the deposit now via credit card/PayPal, or mail in a check.