Internal Environment Institute

E-mail: francerobert@ieihealth.com     Web site: www.ieihealth.com

Registration Form

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First NameMiddle NameLast Name

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Mailing Address

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CityStateZip Code

(____)______________________________________________________________________________________________________________

Daytime Phone NumberFaxemail

Colon Hydrotherapy Course “Basic”

Please check the appropriate box:

I wish to register for the following class:

Dates:  _______________________________________________________        

Personal Information:

       I have taken anatomy and physiology classes at the following school (incl. Hospitals for nurses)

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       I am a certified massage therapist / technician

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       I am currently a client of colon hydrotherapy and have received several colon hydrotherapy sessions. My colon hydrotherapist is: ______________________________________________________________________________________________

       I was referred to this Institute by: _____________________________________________________________________________________

      I am currently working as a: __________________________________________________________________________________________

Do you want to take I-ACT testing? :    YES:   Level #1                NO:

   (I-ACT fees not included in registration)

Method of Payment: Total fee $2,800.00. Please pay the $800 deposit at this time. Remaining $2000 due on first day of class.

    Check # __________ for $800 is enclosed.

    Credit Card (Visa/MasterCard/Discover/American Express)

Credit Card #: ______________________________________________________Expiration Date:_______________________

I declare that the above statements are true and correct.

____________________________________________________________________________________________________________________

SignatureDate

Complete and sign this form and the appropriate Enrollment Agreement and mail with $800 deposit to the above address. Your space in class is saved not only with your deposit but also upon the receipt of your forms.

Balance of $2,000.00 due on the first day of class.