WAIT LIST REGISTRATION FORM
Understanding the Healing Art of Reflexology
With Marie A. Luckhart
Registered Canadian Reflexology Therapist and Certified Instructor
Complete form and return to [email protected]
Understanding the Healing Art of Reflexology
With Marie A. Luckhart
Registered Canadian Reflexology Therapist and Certified Instructor
Complete form and return to [email protected]
I wish to be added to the waitlist registration for the following reflexology courses offered:
Certificate/Professional
Reflexology Core Anatomy & Physiology ___________
Hands-on Foot Reflexology _______ Hands-on Hand Reflexology _______ Hands-on Ear Reflexology ___
Professional Exams ____________
General Interest
Self-care techniques ______ Introduction to Reflexology in Ear ____ Hand _____ Foot ______
First Name _____________________________________ Last Name __________________________________________________
Mailing Address Street ____________________________________________________Unit___________________________
City _________________________________________________________ Prov _________ Postal Code_________________
Age _________ Birthdate ________________________ Phone No. ________________________________________________
Email _____________________________________________________________________________________________________
Current Career ______________________________________________________________________________________________
Are you taking this course for general interest? ______Y/N ______
Are you taking this course for continuing education? ______Y/N ______
Are you are interested in Reflexology as a new career? _______ Y/N ______
Do you have any prior education in the field of reflexology? ____Y /N ____
Explain: ___________________________________________________________________________________________________
Do you have any prior education in the field of alternative health? ____Y /N ____
Explain: ____________________________________________________________________________________________________
Do you have any physical or health limitations that will affect your ability to learn Reflexology? ____Y/N___
If yes, explain to help me accommodate your needs _____________________________________________________________
Do you have any food, animal, or environmental allergies? _____________________________________________________
Additional Comments: ________________________________________________________________________________________
Certificate/Professional
Reflexology Core Anatomy & Physiology ___________
Hands-on Foot Reflexology _______ Hands-on Hand Reflexology _______ Hands-on Ear Reflexology ___
Professional Exams ____________
General Interest
Self-care techniques ______ Introduction to Reflexology in Ear ____ Hand _____ Foot ______
First Name _____________________________________ Last Name __________________________________________________
Mailing Address Street ____________________________________________________Unit___________________________
City _________________________________________________________ Prov _________ Postal Code_________________
Age _________ Birthdate ________________________ Phone No. ________________________________________________
Email _____________________________________________________________________________________________________
Current Career ______________________________________________________________________________________________
Are you taking this course for general interest? ______Y/N ______
Are you taking this course for continuing education? ______Y/N ______
Are you are interested in Reflexology as a new career? _______ Y/N ______
Do you have any prior education in the field of reflexology? ____Y /N ____
Explain: ___________________________________________________________________________________________________
Do you have any prior education in the field of alternative health? ____Y /N ____
Explain: ____________________________________________________________________________________________________
Do you have any physical or health limitations that will affect your ability to learn Reflexology? ____Y/N___
If yes, explain to help me accommodate your needs _____________________________________________________________
Do you have any food, animal, or environmental allergies? _____________________________________________________
Additional Comments: ________________________________________________________________________________________