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Registration Form

Please complete all sections.

Title:

Family Name:

Given Names:

Address:

Phone (h): Phone (w):

Phone (m):

Email:

Brief Description of Profession/Work Background:

Please register me for:

Embodiment in Practice

Early-Bird (by 16 June 2006) Full Payment $1480

Early-Bird (by 16 June 2006) Deposit $310

1st instalment of $600 due by 22 July and 2nd instalment of $600 due by 2 September

Standard (by 14 July 2006) Full Payment $1570
Standard (by 14 July 2006) Deposit $310

1st instalment of $645 due by 22 July and 2nd instalment of $645 due by 2 September

Tracking Emotions in the Body

Early-Bird (by 10 August 2006) Full Payment $396

Standard (after 10 August 2006) Full Payment $450

Note: a 5% discount applies if you register for both courses

Calculated Total (with 5% discount if applicable):     $

Please send your completed registration form along with a cheque for the above amount (payable to Somatic Psychotherapy Institute of Australia) to:

SPIA
62 Llewellyn Street
Balmain 2041
NSW

Alternatively, you may directly deposit the registration fee by EFT to the following account:

BSB Number: 082-125
Account Number: 45 562 2463

A Tax Invoice will be issued to confirm your registration.