SCROLL MENU UP OR DOWN

Confidential Application and Registration

(for Polarity Therapy training only)

 

Class or Workshop______________________________________________________________________

 

Your Name ___________________________________________________________________________

 

Address __________________________________________________________________________

 

City ______________________________________ State ________________   Zip _______

 

Phone (H)_________________________________  (W/C) ______________________________

 

Email ________________________________________________   Birth date _____/_____/_____

 

Emergency Contact Person _______________________________________________________________

 

Phone (H)__________________________________  (W)_______________________________

 

Relationship _______________________________________

 

Date: ____________________________________________

 

Signature: _________________________________________

 

Questions in application are to gain better understanding of student and their needs.

 

Once completed, please print and email to:  

 

Johnny Henderson, Ph.D., BCPP, RPE

SETherapies@gmail.com

Phone: 304-258-9751

 

We will emaill you specific information regarding your Class and/or Workshop.

If you'd like more information, call 304-258-9751.

 

You may also fill out and submit an inquiry through our contact page.

© 2014 SETherapies and Apollo's Haven & Wellness Retreat, Berkeley Springs, WV.  All Rights Reserved.

Johnny Henderson, Ph.D., BCPP, RPE

SETherapies@gmail.com

(304) 258-9751

Tom Langan, RCST® , BCPP, RPE

TomJLangan@aol.com

(703) 628-4551