International College of Healing Arts: Class Registration Form

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International College of Healing Arts ®
A Wholly Owned Subsidiary of
Two Rivers Health
136 Washington St
Binghamton NY 13901
607-724-0830

GENERAL CLASS REGISTRATION FORM

Class Name
Location:		Date:

Please provide following information as you wish it to appear on your certificate & class roster.

What parts of the above info may we share with your classmates (list handed out at end of class) -

Any/All of the above Name Only
Name and: Email Phone #1 Phone #2 Other:

Occupation		Age: Under 18 Adult
Are you requesting CEU's ? No Yes: Please provide License or Registration Number Below
RN License #:	NCTMB #:
Note CEU's may not be available for all classes - Please Check class listing

How did you hear about this class: Personal Referral Poster Flyer Internet Mailing Other
Do you remember who/ where?

The following are optional but extremely helpful to help us cater this class to meet you needs.

Why are you taking this course? What do you wish to get out of this course?

Is there any particular need/reason why you are taking this course?

Are there any particular techniques, skills or applications you plan to use?

Is there any particular area, work setting or situation where you plan to use this material?

This form will email you a copy of your registration. Please print the email and mail it in with your deposit fee.