DANCE MEDICINE PRACTICUM COMPLETION 2016

MODULES III & IV REGISTRATION

Name:  _________________________________________________________________

Address: ________________________________________________________________

Phone: _________________________________________________________________

E-mail: _________________________________________________________________

Occupation:

☐ Movement Educator

☐ Pilates      ☐ Gyrotonic®        ☐ Yoga          ☐ Feldenkrais         ☐ Other

☐ Bodywork/Therapy

     ☐ Physical Therapist     ☐ Occupational Therapist     ☐ Massage/Bodywork     ☐ Chiro     ☐ Other

Years of experience: __________________________________

Name & title to be printed on the certificate:

_______________________________________________________________________

REGISTRATION DEADLINE: NOVEMBER 30, 2015

REGISTRATION FEE:  $1150.00 USD

Payment Options:

☐ Certified Check  (made out to “Long Beach Dance Conditioning, Inc.”)

☐ Credit Card  (including American Express)

        Credit Card Number: ________________ Exp Date: _____ CVV: _____ Billing Zip: ______

DATE: Modules 3 & 4 — March 17-20, 2016

LOCATION: UP Studio in Long Beach, CA (previously LBDC)

Please send completed registration form and payment to:

Marie-José Blom

13050 Mindanao Way #6

Marina del Rey, CA 90292 USA

CANCELLATION POLICY:

Refunds for cancellation of any course greater than four weeks prior to the program start date will be made with the exception of a $100 administration fee. Cancellations for any course less than four weeks before the program are refunded at 50 percent. Requests for cancellations must be submitted via email to the address below. 

Please initial confirming you have read and agree to the cancellation policy above. ___________