Catalog Date: ..................Course Dates:
Name: ............................. Preferred Name / Nickname:
Address:
City: ................................ State: ...........Zip:
Home Phone: ...................Mobile Phone:
E-mail:
Social Security # ............. Birthday:
Occupation: ..................... Healthcare Degrees:

Emergency Contact: ....... Relationship: ......................
Phone#

Have you ever had a colonic? Yes ....No .....How many? ....
Equipment Used:
Previous Colonic Workshop / Classes attended:
What do you expect to do with the experience from this class?

 

How did you hear about the Las Vegas Colon Hydrotherapy School and Clinic?
I-ACT .................... Publication: .................... Friend:
LIBBE/Tiller, Mind & Body.................... Website:
Other:

CREDIT CARD AUTHORIZATION
Card Type: Debit MasterCard Visa Discover American Express
Card Number:		Amount: $
Name on Card:		Expiration Date:
Last 3 #’s on back of card:
Driver’s License Number and Issuing State
Billing Zip Code:	Phone # of Cardholder:

***REFUND / CANCELLATION POLICY***
I understand the deposit required is $400, of which $100 is non-refundable but may be applied to future classes depending upon availability. The $300.00 balance of my deposit may be refunded though a seven (7) day written notice would be appreciated.  ALL FEES must be paid in full on the FIRST DAY of CLASS.  THERE ARE NO EXCEPTIONS! I am fully aware no credit or reduction in cost or hours will be given for any previous training. I also realize that job placement is not promised or guaranteed but resources will be provided when available.
Registration is not valid until all information is completed and processed.