Enrollment Form

COLON HYDROTHERAPY – FOUNDATION LEVEL I
100 HOUR COURSE ($2700) + I-ACT ($225)

Catalog Date:………………Course Dates:
Name:……………………….. Preferred Name / Nickname:

Address:
City:………………………….. State:………..Zip:
Home Phone:……………….Mobile Phone:
E-mail:
Social Security #…………. Birthday:
Occupation:………………… Healthcare Degrees:

Emergency Contact:……. Relationship:………………….
Phone#

Have you ever had a colonic? Yes ….No …..How many?….
Equipment Used:

Previous Colonic Workshop / Classes attended:
What do you expect to do with the experience from this class?

 

How did you hear about the Las Vegas Colon Hydrotherapy School and Clinic?
I-ACT ……….………. Publication: ……….………. Friend:
LIBBE/Tiller, Mind & Body……….……….Website:
Other:

CREDIT CARD AUTHORIZATION
Card Type: Debit MasterCard Visa Discover American Express
Card Number: Amount: $
Name on Card: Expiration Date:
Last 3 #’s on back of card:
Driver’s License Number and Issuing State
Billing Zip Code: Phone # of Cardholder:

***REFUND / CANCELLATION POLICY***
I understand the deposit required is $400, of which $100 is non-refundable but may be applied to future classes depending upon availability. The $300.00 balance of my deposit may be refunded though a seven (7) day written notice would be appreciated.  ALL FEES must be paid in full on the FIRST DAY of CLASS.  THERE ARE NO EXCEPTIONS! I am fully aware no credit or reduction in cost or hours will be given for any previous training. I also realize that job placement is not promised or guaranteed but resources will be provided when available.
Registration is not valid until all information is completed and processed.