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

Phone: 304-258-9751


We will email 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

(304) 258-9751

Tom Langan, RCST® , BCPP, RPE

(703) 628-4551