Application Form
Please send the completed form to:
Three Treasures School of Traditional Chinese Medicine,
60 Fore Street,
North Petherton, Bridgwater , Somerset,
TA6 6QA
(Please attach a recent passport-size photograph)
(PLEASE COMPLETE THE FORM USING BLOCK CAPITALS)
Your First Name_____________________________________
Your Last Name_____________________________________
Title (Mr. Miss, Mrs, Dr etc)___________
Date of Birth___/____/___________
Address_____________________________________________________
Postcode:_________ Email _____________________________
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 Diploma Course and am applying for a place on the course.
I declare that I am fit enough to perform Qigong exercises.
Fees (Please delete where not applicable)
I wish to pay the Discounted fee in advance
I would like to pay monthly by Standing Order
I would like to pay by PayPal
_______________________________ ______/ ______/
(Signed) (Date)
