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
187 Parfitt Way SW, Suite 215
Bainbridge Island, WA 98110
Two Professional References
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.
Please wait to submit payment until you have been notified of your acceptance into the training. Once you have been accepted, you may pay be check as noted below, or to pay by credit card, click here
Now accepting applications for the program beginning March 2, 2012
