The Modern School of Ancient Therapies


      Title: Mrs/Miss/Mr/Ms

First Names:

      Date of Birth:


      Telephone No:


      Mobile No:

Town/City:       Email Address:



Reasons for application?

Where did you hear about us?

Do you have any mental or physical challenges?

Who is funding the course? i.e. Self/Employer/College

Please state below which courses and dates you wish to apply for:

I have enclosed a non-refundable deposit of 50 per course

I have enclosed the full balance of the course
I require a kit and enclose full payment

The total cost for course

Please note: We accept cash, cheques BACS and IBAN payments. We do not accept Credit or Debit cards. Please make cheques payable to The Modern School of Ancient Therapies.  Payments by BACS 090666 42112278  IBAN GB60ABBY09066642112278
Thank you.

Please print the completed form then sign and date it and send to:
The Modern School of Ancient-Therapies, 10 Duck Street, Clitheroe, Lancashire, England BB7 1LP

Signed:                                                                               Dated: