GAIA Amatsu Therapy Training Application

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Who was or is your Amatsu Therapist?

First Name

Last Name

Do you have a disability, significant health problem and/or specific learning difficulty?

Provision of the information in this section is requested to enable the GAIA to accommodate, where reasonable, your needs. All information provided will be treated with sensitivity and in as confidential a manner as possible.

No

Yes

Name of referee *

You must provide details for one referee that will provide you with a character reference on request. Ideally this would be your Amatsu practitioner. If you would like to use some one else as an alternative, please explain below why this person is suitable and their standing in the community.

First Name

Last Name

I certify that the information provided in this application is accurate and correct. *

Yes

No