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TREE OF LIFE CENTER 
Somatic Energy Healing Training Application
150 hr. Polarity Therapy Continuing Education Courses
we are Nationally Certified Continuing Education Provider with NCBTMB  # 3129991-00 



Name _______________________________     Date of Birth _________________
Address____________________________________________________________
Phone’s (cell) __________________________(Other)________________________
Email______________________________________________________________
Occupation__________________________________________________________
NC LMBT Licence #__________________ for Continuing Education or
I plan to take this course for SELF-CARE and Sharing with Family & Friends ________

On a separate sheet or via email briefly answer the following:
A. Why are you interested in studying polarity and what are your intentions or goals with participating in this training?
B. Describe pertinent training, experience and bodywork you have received.
C. Describe your learning needs to help us support your development.
D. Describe your learning gifts that you can bring to the group.
Do you receive or have you received Somatic process oriented bodywork before?
 Please describe whether you have personal/medical conditions (physical, emotional, mental) which may affect the quality of participation in classroom activities such as movement and Gentle Energy Yoga/attendance or coursework completion or that could get stimulated in the training environment.
Are you willing to reach out for resources and support to counselors or Somatic practitioners if you are needing that during the training period if things are coming up for you?  
Describe any resources or things that help you when you are stressed out.
Do you have any dates that you are unable to participate in the 

Completed application & application fee of $200 deposit is due to reserve your space.  

     Checks made out to Janice Durand and mailed to:
 Tree of Life Center
 4316 Bradford Ridge Road
Efland, NC 27243
  jmdchi@mindspring.com

~ Pre-requisite class of at least two days of one of our Intro’s to either Energy Healing or Chakras & Elements needed to participate or possibly another class that you have taken with Tree of Life Center.  

   Tree of Life Center Somatic Energy Healing
Payment Contract  

The Somatic Energy Healing program offered by the Tree of Life Center is an Advanced 
Continuing Education professional practitioner training program that is registered with the International Polarity Education Alliance. (IPEA) and we are a Nationally Certified Continuing Education Provider with NCBTMB  # 3129991-00 
A $200 deposit is due by the 1st week in Oct. 2017 to hold your place.  This payment will go toward tuition and your final payment.   OPTIONS FOR PAYMENT:


~TOTAL TUITION for all Modules:   $2800
    Deposit to hold space Oct. 1, 2017:  Date ____ Amount: $200 _______

  9 Month Payment Plan

1st Payment:       January 26, 2018          Amount: $ 325   _______
2nd Payment:      February 23, 2018        Amount: $ 325   _______     
3rdPayment:        March 23, 2018            Amount: $ 325   _______ 
4th Payment:        April 27, 2018               Amount: $ 325 _______
5thPayment:        May 18, 2018               Amount: $ 325 _______
6th Payment:       June 22, 2018              Amount: $ 325 _______
7th Payment:       July 27, 2018                Amount: $ 325 _______
8th Payment:       August  24, 2018         Amount: $ 325 _______

(all checks made out to Janice Durand)

Any changes in this agreement will be negotiated promptly and 
a new contract drawn up no later than ten days prior to the beginning of the program.

Name of Student making this contract:________________________
Address:______________________________________
                  City:_________________ State_______Zip__________
Telephone #’s  cell:(_____)___________  Other: (_____)___________
 e-mail______________________

I understand the terms of this contract and agree to fulfill them as 
specified above.  Signature____________________________  Date______
 
Tree of Life Center 4316 Bradford Ridge Road,  Efland,  North Carolina 27243
(919) 563-4454         jmdchi@mindspring          www.TreeofLifeCenterNC.com
      

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