VM treatmentVM treatment

Registration Form

 


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Registration Form

Personal/Professional Details

Title:

Surname:
Forename:
Therapy/Qualifications*:

*It is assumed that you are a professionally established and qualified healthcare practitioner. Any doubts about this must be raised with us in case the signing of an appropriate Waiver is required.
Address/Contact Details
Postal address:
Physical address
(if different):
Country:
Telephone home:
Telephone work:
Mobile Telephone:
Contact phone for public**:
Fax:
E-mail:

Website:

Course details
Name of course:
Start date of course: Day: Month: Year:
Course location:
Equipment you can bring: treatment table
  yoga or camping mat
Other

If this is your first Barral Institute UK course,  how did you hear about us?

**Please indicate whether you would like your name and public contact number to be published upon completing the course in  directories of visceral manipulation and online at www.iahp.com.

Yes, please publish No, I do not wish to have my name listed.

I understand that all of the above information will be relied upon in confirming my place and in setting up my file.
Payment

Please note a deposit of £200 is required to secure your place on the class.

Select payment method: Cheque
Bank Transfer
Credit/Debit card (4% processing fee applies)

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Address: Barral Institute UK

26 Miller Road

Ayr KA7 2AY

Tel/fax: 01292 266335

Email: info@barralinstitute.co.uk