First Name
Last Name
Street Address
City
State
Zip
Phone
Email
Educational Degree
Licensure
Do you have any past or
pending actions against
your license?
If yes, please explain
(confidential)
Describe your interest in this training including any similar education you have received and a general description of your current practice
Payment Method
To pay by check, make check payable to Sharon Stanley, Ph.D and send to:
Somatic Transformation
6172 Old Mill Rd NE
Bainbridge Island, WA 98110
To pay by credit card, please contact Linda Derosiers at
somatic.transformation@gmail.com or
206.780.2205
in order to arrange for receipt of credit card information
Two Professional References
Name
email
Phone
Name
email
Phone
Are there any learning accomodations* you will need or anything that will assist the instructor in your successful participation in this training?
* Somatic Transformation does not discriminate for consideration for admission based on sex, race, age, sexual orientation or religion. Requests for accomodations will not affect the admission decision.
REGISTRATION CLOSED AT THIS TIME
