ASA Pain Relief Therapies by Alison Sue Adams

Application For Enrollment

To apply, please print a copy of this form, fill it out, and submit via fax: 561-848-3908. Or mail to the address at the bottom of this page.

If you have questions or want more information, call us toll free:
877-691-4455 or click here to send us an email.

Enrollment Information
  
Course: Start Date Course: Start Date
MET01 __________   EASY Courses  
MET02 __________ Hip and Legs __________
MET03 __________ Neck and Shoulders __________
MET04 __________ Craniosacral __________
CIAT __________      
  
Personal Data
  
Name (Last, First, Middle):
 
Address Line 1:
  
Address Line 2:
  
City, State & Zip:
  
Home Phone:
   		Work Phone:
  
Fax:
   		Email:
  
Male Female Birth Date (mm/dd/yy):
  
  
Emergency Contact Information
  
Name (Last, First):
   		Relationship:
 
Home Phone:
   		Work Phone:
  
  
Professional Background
  
Type of License
   		School and Completion Date:
If currently a Massage Therapy or Bodywork student, where are you enrolled and what course and clinic work is still needed for completion?
  

 
  
CIAT APPLICANTS ONLY: Please include a picture of yourself, a short essay explaining your reason for wanting to take the course, and a history of your professional experience.

 
Applicant's Name

   		Today's Date (mm/dd/yy)

  
Applicant's Signature

  
  
Application Fee: A $100.00 NON REFUNDABLE deposit is required with this application to reserve space for enrollment. This deposit will be applied to the course fee.

Cancellation Policy: The deposit is NON REFUNDABLE. However if cancellation notice is received in our office 2 weeks ahead of the class start date, funds received less a $50.00 processing fee may be applied to a future class. No credit will be given for cancellations made less than 2 weeks from the class start date.

Payment: Payment may be made via Visa, Master Card, American Express or by a check from a USA bank.

 
Type of card: Visa  Master Card   American Express Check Enclosed
Credit Card Number

   		Expiration Date (mm/dd/yy)

  
Name on Card

   		Today's Date (mm/dd/yy)

  
Cardholders  Signature

  

The Right Tool for the Job!

ASA Pain Relief Therapies, Inc.
749 U.S. Highway One, Suite 125
North Palm Beach, Florida 33408 Map
(561) 848-3902  Toll Free 1-877-691-4455
Email info@asapainrelief.com
  

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