Master Training:  Registration Form

Name___________________________________________________________________________

Street, City, State, Zip_____________________________________________________________

Work Phone ____________________________      Home Phone __________________________

Fax ____________________________________     E-mail _______________________________

Order the videos if you need them to practice.  Enclose a deposit of $500 (check, visa or master card).  $250 of the deposit is transferable but not refundable.  I am registering

for:_________________________________________________   (List workshop dates)

In order to assist me in reviewing for the course, send me the following videos @ $35/DVD or, $150/set:   

�        #1  Feet and Lower Legs

�        #2  Hip and Thigh

�        #3  Chest and Back

�        #4  Arms, Shoulder, Neck

�        #5  Introduction to Posture Balancing

        Total cost of videos $_______ plus $3/video ordered for postage & handling = $_________

 �        I have enclosed a check for $__________ ($500 for registration plus amounts for any video orders) made out to Myopractic^� Institute.

 �        Please charge my credit card for $_________  ($500 for registration plus amounts for video orders):

Card Number ___________________________________________       Exp. ______

     Signature __________________________________________________________

Please read and sign this Statement of Purpose:

I intend to participate in the Myopractic^� Master Training.  I realize that the training requires me both to receive and to give structural integration bodywork that is designed to change profoundly the muscle and postural patterns of the body.  These body changes may also foster change in my thinking and behavior. 

 Furthermore, I realize that I will have an option during the training to give and receive structural integration techniques and patterns using power tools (buffers and percussion instruments) designed to create deep release by putting vibration into the body.

 Finally, I realize that I will have an option during the training to receive energetic re-integration (ERI) techniques designed to accelerate and move large amounts of energy in the body.  ERI techniques may create a temporary shift in my state of consciousness that will be unique to me.

 I accept all benefits and risks associated with the training as described above.

 Signature __________________________________________________________________

 Print Name _________________________________________ Date ___________________  

Mail completed registration form to: 

Myopractic^� Institute, 3011 Hwy 30 West, #101-222, Huntsville, TX 77340 

Fax to:  936-435-1379.  or call us at 1 (936) 435-1329 for additional information.

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