BIODYNAMICS PROGRAM - COURSE REGISTRATION FORM

To register for a course offering complete the information below and return with payment by the registration deadline date. The course fee is $650.00. Registration is on a first-come/first-serve basis. 

To register for courses with Dr. Hankinson or Dr. Hagopian please refer to the course listing for the registration process.  This form is for courses with Dr. Jealous only.  

Name:
Degree Title:		AOA#:
Address:
City:		State:
Country:		Postal Code:
Phone:		Fax:
E-Mail:
College of Graduation(name and address)
Yr of Graduation:		Type of Practice:
Prior training in the Osteopathy/Cranial Field(s) including any Biodynamics Courses you have completed:
Phase(s) Desired:		Date:
Instructor:		Location:
Have you taken this Phase before?		Payment: $
Please enter the required code listed below. If this form does not forward to me please return to this page and re-enter the code below.
Code:
Verify Code:

**If you are interestd in a course that is “closed” and would like to be put on our waiting list, please contact us and we will be glad to put you on our waiting list.

Payment Information: Check or money order made payable to James S. Jealous, D.O. No postdated checks, please. We are unable to accept credit cards. A fee of $35.00 will be charged on all returned checks. CANCELLATION POLICY: There will be a $250.00 cancellation fee for cancellations made 21 days or less prior to a course.

Send Payment and Registration Form by the deadline date to:
Marnee Jealous Long
Longtide Management Inc.
6501 Blackfin Way
Apollo Beach, FL 33572
(813) 765-5005 phone or (813) 649-0760 Fax
mjllong@verizon.net


Dr. Jealous reserves the right at any time to deny an individuals request for course enrollment and/or attendance to the course.