Registration

Somatic Transformation Training Program
January 2016-2017

Now accepting applications for the program beginning January 22, 2016. Payment options are listed at the bottom of this page.

Somatic Training Registration

Fields marked with an * are required

First Name*

Last Name*

Address*

City*

State*

Zip / Post Code*

Email*

Educational Degree*

Licensure*

Do you have any past or present actions against your license?* (yes or no)

YesNo

If you answered YES to previous question, please explain below:



Professional Reference 1*

Email Address 1*

Phone*

Professional Reference 2*

Email Address 2*

Phone*


Describe your interest in this training including any similar education you have received and a general description of your current practice.*

Are there any learning accommodations** you will need or anything that will assist the instructor in your successful participation in this training?*

Payment Method*
CheckCredit Card

**Somatic Transformation does not discriminate for consideration for admission based on sex, race, age, sexual orientation or religion. Requests for accommodations will not affect the admission decision.

Please wait to submit payment until you have been notified of your acceptance into the training. Once you have been accepted, you may pay by check as noted below, or pay by credit card.

To pay by check, make check payable to Somatic Transformation and send to:

Somatic Transformation
187 Parfitt Way SW, Suite 215
Bainbridge Island, WA 98110