EmailMe Form - Thai Massage Certification Agreement

I am applying for the Thai Massage Certification Program beginning *

MM / DD / YYYY

Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

In case of emergency please contact: *

Phone *

### - ### - ####

How many years have you practiced yoga? *

Do you have a regular yoga practice? *

Yes

No

Third option

How frequent is your current practice? *

Daily

4-5x/wk

2-3x/wk

Current Teacher's Name:

Yoga Style/Tradition Practiced:

Do you have a regular meditation practice? *

Yes

No

Third option

Past Yoga Experience, Styles or Traditions

How did you find out about Source Yoga Studio's Thai Massage Certification program?

I agree to pay $933 plus GST on or before the first day of classes. *

Yes

No

Third option

If "No", please state what arrangements have been made with Dillon Cherrett.

Refund Policy
$500.00 with application is non-refundable.

If you are accepted into the program and are unable to participate, you will be refunded your full tuition, minus the deposit to
reserve your space. Notice must be received in writing no later than 30 days prior to the start of the program. Once training has commenced, there are no refunds. *

Agree

Disagree

Third option

I have read and understand all the above criteria for certification as a Thai Massage Practitioner through the Source Yoga Thai Massage Certification program. *

Yes

No

Third option