ENROLMENT FORM
Please send the completed form to:
Three Treasures School of Traditional Chinese Medicine passport size
60 Fore Street, North Petherton, Bridgwater photograph
Somerset TA6 6QA
(PLEASE COMPLETE THE FORM USING BLOCK CAPITALS)
Your First Name_____________________________________
Your Last Name_____________________________________
Title (Mr. Miss, Mrs, Dr etc)___________
Date of Birth___/____/___________
Address_______________________________________________________
PostCode___________________TelephoneNo._______________________
Email address:__________________________________________________
Do have any previous experience or qualifications Qigong and/or Traditional Chinese Medicine? Yes/No (please delete as applicable)
If YES please enter a description below:
Do you have any qualifications/ experience in Anatomy and Physiology?
Yes/No (please delete as applicable)
If YES please give information here:
I have read and understood the details of the Medical Qigong Certificate/Diploma Courses and am applying for a place on the following courses Course/s.
Please state which course or courses (one only or both): ______________________________________________________________
I declare that I am fit enough to perform Qigong exercises.
. I understand that details of payment of fees will be sent to me with the letter of acceptance onto my chosen Course/s.
_______________________________ ______/ ______/
(Signed) (Date)
