The Modern School of Ancient Therapies
 COURSE APPLICATION FORM
 
Surname:

       Email Address:

First Names:

      Date of Birth:

Address:

      Telephone No:

Address:

      Mobile No:

Town/City:       Occupation:

Postcode:

     Qualifications held:

Reasons for application?

Where did you hear about us?

Do you have any medical problems/contra-indications?

Who is funding the course? i.e. Self Financing/Employer/FE 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 only cash and cheques. We do not accept Credit or Debit cards. Please make cheques payable to The Modern School of Ancient Therapies.
 Due to limited class numbers, places can only be provisionally booked by telephone and held for 7 days only.  We apologise that places cannot be guaranteed unless £50 deposit and application forms are received by post.  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 BB7 1LP

Signed:                                                                               Dated: