formulier

The Dutch School for Classical Shiatsu

Registration form

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Personal info:

Surname *

Initials *

Name *

Date of Birth *

Day Month Year

Gender *

I am new to the school *

Add a personal pasport sized photo.

Accepted file types: .jpg, .jpeg, .png, .gif. Maximum filesize: 250KB

Address:

Street *

House number *

Post code *

Reachability:

City *

Country *

Phone number *

Extra Phone number

E-mail *

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Profession *

Current education level

High School College University Bachelor University Master Para Medical Other

Other

Current level N.S.K.S.

How did you hear about the school?

Internet Newspaper add "Onkruid Gids" Magazine Other

Other

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I would like to subscribe myself for the following: (Multiple options possible) *

Course (Basic course - Do-In for women) *) Seminar (Year Y. Kawada Sensei - Diagnostics - Moxa - Meridian - Lunteren - Macrobiotic cooking) *) Diploma Course **) Diploma Course Exams ***)

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Course *)

Start date of the Course

- Day - Month Year

I would like to subscribe for a second course

Yes

Second Course *)

Start date of second Course

- Day - Month Year

To view Course dates, click here. (This link will open in a new page)

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Seminar *)

*) Accredited as postgraduate education- higher vocational education

Start date of the Seminar

- Day - Month Year

I would like to subscribe for a second seminar

Yes

Second Seminar *)

*) Accredited as postgraduate education- higher vocational education

Start date of second Seminar

- Day - Month Year

To view Seminar dates, click here. (This link will open in a new page)

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Diploma Course **)

Start date of Diploma Course

- Day - Month Year

To view Diploma Course dates, click here. (This link will open in a new page)

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Diploma Course Exam ***)

Start date of Exam

- Day - Month Year

I would like to subscribe for a second Exam

Yes

Second Diploma Course Exam ***)

Start date of second Exam

- Day - Month Year

Your exact name to be written on your Certificate/Diploma:

To view Exam dates, click here. (This link will open in a new page)

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Physical complaints and/or specific illnesses:

Comments:

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Judicial declaration:

Undersigned declares to have filled in the form truthfully, to agree with the Conditions & Terms and to be informed of the payment terms as also described on www.shiatsu.nl

I unconditionally agree with the General Terms and Conditions *

Yes

I give permission to share my adress information with fellow students *

Yes No

I would like to receive the school's Digital Newsletter *

Yes No

Enter the message as it's shown *

*) Admission occurs by chronological order of received payment.

**) Undersigned has read, understood and agrees unconditionally with the general terms and conditions set by the Dutch School for Classical Shiatsu to be allowed to take part in a level on the diploma course. The total amount of a diploma course level is € 1100,- (incl. submission fee of € 350,-). If the whole amount is being paid at once, with a minimum of one month before commencement of the level concerned, a discount of € 45,- is being granted. There is a possibility to receive a payment contract, only when requested largely in advance at the secretariat. In this case the full amount has to be paid within three months after commencement of the level concerned. The submission fee will be € 390,-, the total amount for the diploma course level € 1100,- + administration costs. Admission occurs by chronological order of received payment.

***) Undersigned has read, understood and agrees unconditionally with the general terms and conditions set by the Dutch School for Classical Shiatsu to be allowed to take part in Exams. The examination fee of € 75,- ( € 85 for Level 4) must have been paid to the account number mentioned below at the latest of one month before the examination date, indicating the examination level and examination date.

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Secretariat: Stuyvesantstraat 24, 2593 GM, Den Haag, 070 - 383 15 00 - K.v.K (Den Haag): 27156302. Bank: NL38ABNA 056.84.25.502 www.shiatsu.nl - klassieke@shiatsu.nl