Class Registration


Thank you for your interest in attending

Please make sure to fill in all fields and text boxes.

Full Name:

Email address:

Phone (including area code):

Address:

City/State/Zip: / /

Country:

Please tell us a little about your experience with Energy Chiro. How have you used Energy Chiro with clients or in self-care? Pre-requisite for this advanced Energy Chiro class is Energy Chiro I -- Have you taken E. Chiro I live, or via DVD?

What are your hopes or expectations for this class (if any)?

Are there any health, mobility, mental health, or learning issues we should be aware of?

Payment options (please select one, payment information will be provided on next page):
I wish to pay the full US$300 Fee.
I wish to pay the $100 Deposit.
I wish to pay by Check.

Additional details will be sent with confirmation of registration.

By submitting this form I certifiy that all the information is accurate.

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