AROMANSSE FORM

To register, kindly complete one form per person and email or mail it with your deposit to :

Aromansse. 323 King Edward Street, Winnipeg, Manitoba, R3J 1L6

winnipeg@aromansse.com

First Name: ___________________________ Last Name: _____________________

Name you like to be called _____________ Date of birth: _________ Sex: ______

Address: ____________________________________________________________________________

City: _______________________ State/Prov.: _________Postal Code: _________ Country: __________

Home phone:( ____ ) __________ Business phone:( ____ ) ___________ Fax:( ____ ) ____________

E-mail: ____________________________________________________________________________

Married: ____ Children: _____ Occupation: __________

Presently on medication? (specify kind and amount) __________________________________________________

Any chronic or major illnesses, or physical limitations we should know about? ____________________________

General health? ______________________ Do you smoke? _______

Have you ever taken or practiced meditation before? _________________________________________________

Have you utilized any Hemi-Sync tapes or CDs since your Program participation? ________

If so, which ones and how often have you used them? ___________________________________________________

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Have you had any difficulties with any of the TMI taped exercises? Yes____ No _____

If yes, please explain: ________________________________________________________________________________

What other Aromansse programs have you attended? ______________________________________________________

Have you ever had a massage? (How often)______________________________________________________________

Have you ever taken or practiced Yoga before? ___________________________________________________________

Have you experienced energetic work? E.g., Reiki, Junjou Hado, Therapeutic touch etc.

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What areas of personal development do you feel you need most? _____________________________________________

__________________________________________________________________________________________________

What specifically about this program motivates you to attend? _________________________________________________

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Anything else about you that would be useful for your Aromansse instructor to know?

____________________________________________________________________________________________________

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I, ___________________________________, desire to participate in the Aromansse Meditation Classe Level __________, scheduled to be held at The Aromansse Studio in Winnipeg.

I enclose my entire meditation course fee of $159, tax included on or before the first day of class.

Tuition is not refundable. Credit Cards are not accepted for meditation tuition.

What is your method of payment?

Cheque

Post-dated cheques,# ____

Cash

Signature