Registration Form

(If you are a singer, please use this registration form instead.)

Please fill in this form and submit it by clicking the button at the end. (The fields marked with a red asterisk are required.) You can expect to hear back from me within 48 hours.

I look forward to working with you!

Part A: Please fill in your personal information

Full legal name: *

If you use a different name or nickname socially, please type it here:

Birthdate:

Home address:

Email address: *

May I send you the next issue of my email newsletter?:

Yes

(You will be given a choice of receiving further newsletters or unsubscribing.)

Phone number(s): *

Occupation:

Part B: Please list someone to call in case of emergency

Name:

This person's relationship to you:

Phone number(s):

Part C: How did you hear about me?

Source:

From someone you know. Please tell me who it was.

From a web search. Please list the search engine and phrase you searched on.

From a link on another website. Which site?

Other (please explain).

Source detail:

Part D: What are you registering for?

Types:

Alexander Technique lessons or programs

Tablework

Both

Want to find out more about Tablework?:

Yes, I'd like to schedule a complimentary introduction to Tablework.

No, thank you.

Tablework is my own way of working with clients on the table to relieve stress and tension and reduce pain and dysfunction. Tablework is performed with the client fully clothed. It incorporates elements of various bodywork techniques as well as the Alexander Technique.

Part E

Are you currently suffering from pain or other physical trouble?:

Yes

If yes, please describe.:

List any surgeries, serious injuries or diseases, or other pertinent medical history:

Part F

Please read the following medical disclaimer, then type in your full name, which constitutes your online signature.

The Alexander Technique is an educational process and not a form of diagnosis or treatment or healing. Tablework may assist your body in its self-healing process, but it is intended to complement medical care, not substitute for it. Some conditions may require intervention from a medical doctor or other health professional. You must inform Michael of any relevant changes in your medical status, including episodes of pain or discomfort, that arise while working with Michael.

Signature (Enter your full name): *

Date: *

Part G

Please read my policy on lateness, cancellations, and payments, then type in your full name, which constitutes your online signature.

You must arrive on time for appointments and may be required to pay the full fee for any appointment shortened by your late arrival. Since there is no waiting area in Michael's studio, you may be requested to wait downstairs in the main lobby of the building until your appointed time if you arrive more than 5 minutes early.

You must give at least 12 hours’ notice to cancel an appointment. Unless there are extenuating circumstances (to be determined by Michael), you may be required to pay in full for any appointment cancelled without sufficient notice. (All clients are granted one free waiver of this policy every six months to accommodate occasional emergencies.)

Each lesson/session must be paid for in full at your appointment by cash or check or before the appointment by credit/debit card through Paypal. If a check you write is returned unpaid by your bank, Michael will assess a $15 processing fee and may elect to require payment by cash or credit/debit card in the future.

Signature (Enter your full name): *

Date: *


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