REGISTRATION FORM

Course Location: Queen West Physiotherapy 345 Queen Street West Brampton, ON L6Y 3A9 Unique Mentorship Program:

Tom offers ongoing mentorship just a phone call away or by email at any time in order that your reinforce your newly acquired knowledge and gain 100% confidence in immediately using your acupuncture skills for optimal effectiveness.

*NOTE: a minimum of 15 registrants required for each course (we will notify you one week prior to August 25th if the required number has not been reached, and you will receive a refund if courses have been cancelled).

Also, a Cupping set is included in the price!

For Fastest Sign- Up call 905- 450-7870 or complete and fax/mail the form below:* Please check your option below.

YES! Sign me up for the __Cupping & Gua Sha____ Course on October 27th for $300 ( Gua Sha Stone and small Cupping Set OR $330 ( Gua Sha Stone and large Cupping Set)

*PLEASE PRINT IN LARGE CAPITAL LETTERS

Cheque enclosed (make payable to Queen West Physiotherapy and Acupuncture, post-dated for 1 month prior to course date)

Please charge to my: Visa MasterCard

Card Number: _______________________________________________

Expiry: ______________

Name: ______________________________________________________

Street Address: ______________________________________________

City/Province: ______________________ Postal Code: _____________

Phone: (_________) __________________________________________ (In case we have questions about your information)

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Signature: ______________________________________

Fax to: 905-450-0920

Mail to: Queen West Physiotherapy and Acupuncture 345 Queen Street West Unit 1, 3, 4 Brampton ON L6Y 3A9

Meridian Health Education, C/O Queen West Physiotherapy & Acupuncture,345 Queen Street West, Units 1, 3 and 4 Brampton, Ontario L6Y 3A9t: 905.450.7870 f: 905.450.0920 e: info@learnacupuncture.ca

Complete Satisfaction Guarantee:If you are not completely satisfied with our Cupping course, let us know and you will receive a refund*

Lowest Price Guarantee: Our program gives you the most “bang for your buck”, you will not find another program as unique as ours for such a great price.

*Refund Policy: For registrants of single day courses: No refunds for cancellations 2 weeks or less prior to course date. Refund minus a $50 per course administrative fee is provided if notice is given prior to 2 weeks or more before course date.