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日本語インフォメーション
"Please answer all questions listed below in English"
Please fill out all the information below
日本語申込書
はプリントアウトして、ファックスにてお送りください。
ファックス番号62-361-736 740
My Information
Name:
E-mail Address:
Phone number:
Height:
Weight:
Sex:
Do you have any physical limitations
that we need to know about?
Do you have allergies or food restriction
that we need to know about?
Have you had any illness or surgery
in the last year ?
Yes
No
If yes, please explain :
Hotel Information
Name:
Address:
Phone number:
Questions to Answers
1
.
Do you need a translator
No
Yes
2
.
Language needed
if you need translator
(additional charge will apply)
3.
I am taking this class for :
Personal growth
Professional growth
4.
I am a massage practitioner and
have a private massage practice
work in spa
teach massage
5.
I have studied: Please mark each modality and write in other areas of study
Thai Massage
for
(weeks/months/years)
Aromatherapy Massage
for
(weeks/months/years)
Shiatsu Massage
for
(weeks/months/years)
Deep Tissue Massage
for
(weeks/months/years)
Cranial Sacral Work
for
(weeks/months/years)
Reiki
for
(weeks/months/years)
Yoga
for
(weeks/months/years)
Dance
for
(weeks/months/years)
Movement Practice
for
(weeks/months/years)
Other (Please list)
for
weeks/months/years
I want to Register for workshop:
Massage Appreciation Classes - Exploring Basic Massage - 1 Day Class
Half Day Introductory Courses includes: Yoga, 3-hrs Class, Lunch and 90-min Massage
Massage Appreciation Classes - 2nd Day Class
(optional)
Wednesday following tuesday class
Jari Menari Sequence Massage - 12-days of Class over 2 weeks
April 9-26, 2012
Basic Touch Techniques Private Classes
Desired Date for workshop: First choice:
Second choice:
Time :
morning
afternoon
Enhancing Your Delivery: Custom Designed Workshop for Massage Practitioners
Desired Date for workshop: First choice:
Second choice:
Time :
morning
afternoon
Number of Students :
Additional Information:
I will stay in Bali for :
days
