Course Registration for Qiological Listeners First 3 Ojai Registrants will receive a signed copy of The Tao of Trauma by mail Name*Email*We have been having problems with certain email providers, including Yahoo and AOL. If your primary email is with YAHOO or AOL, please also leave an alternate email below. Alternate EmailFor YAHOO and AOL users Phone Number*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country I am licensed as a:*AcupuncturistCounselorMassage TherapistNursePhysicianPsychologistSocial WorkerOtherPlease enter "Other" Professional Affiliation here:For NCCAOM PDAsPlease provide your State Acupuncture license #, NCCAOM #, and date of birth if you would like NCCAOM PDAsBIPOC, LGBTQ+, or First-Generation Immigrant?In the spirit of cultural transformation through healing, if you are BIPOC, LGBTQ+, or a first-generation immigrant, please check this box to receive 25% off fees. BIPOC, LGBTQ+, or first-generation immigrant I am registering for:EARLY BIRD single payment ($2,000)Two payments ($1,150 each)Four payments ($575 each)Other (please enter amount below)I am registering for:Fees reflect 25% discountEARLY BIRD single payment ($1,500)Two payments ($862.50 each)Four payments ($431.25 each)Other (please enter amount below)Other Payment AmountEnter other payment amount here. If registering for "Other" please provide details here2024-25 Tao of Trauma Cohort*Which cohort are you registering for?In Person in Silver Spring, MDIn Person in Thousand Oaks, CAVirtual Live-StreamAffinity "Pods" in Virtual CohortIf you wish to be placed with others in an affinity group for practice sessions and discussion groups ("pods"), please select the affinity group(s) you prefer. Note that we need at least three people to create an affinity-based discussion group ("pod") and at least two to create an affinity-based practice pairing. BIPOC LGBQT+ First-generation immigrant Covid Policy Acknowledgment*Required for those registering for in person Silver Spring or Thousand Oaks cohortsI have read the Covid 19 Policy and Release of Liability WaiverNot applicable (Virtual cohort)Payment Method*Checks should be made payable to "Integrative Healing, LLC" and mailed to Integrative Healing, LLC, PO Box 204, Hyattsville, MD 20781. Receipt of your fee will hold your space. Cancellations made 30 days prior to the first day of series will receive full refund, less $100 admin fee. Other cancellations will receive pro-rated credit towards a class held in the next 18 months.Credit CardCheckTotal $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name CommentsHow did you hear about us?Would you like to be added to Integrative Healing's email list?Already receiving your emailsYesNo Simplicity MetricsCourse Registration for Qiological Listeners07.31.2019
