Application for Full 145 hour
Herbal Program 2007-2008
Name________________________________________Phone_____________________
Address______________________________________City, State Zip______________
Email________________________________________DOB______________________
Emergency
Contact_______________________________________________________
Favorite Plants (up to 5)
____________________________________________________________________________________________________________________________________________________________________________________________________________
Applicable Training Since
High School / Dates / Degrees and/or Training
____________________________________________________________________________________________________________________________________________________________________________________________________________
Applicable
Professional/Job/Project History
____________________________________________________________________________________________________________________________________________________________________________________________________________
Previous
Health/Medical/Healing Work
____________________________________________________________________________________________________________________________________________________________________________________________________________
Special
areas of interest in Herbal Medicine?
____________________________________________________________________________________________________________________________________________________________________________________________________________
Do you have any special needs(allergies, disabilities)?
____________________________________________________________________________________________________________________________________________________________________________________________________________
What do you plan on doing
with this training?
____________________________________________________________________________________________________________________________________________________________________________________________________________
Do you have any personal expectations from this
program?___________________________________________________________________________________________________________________________________________________________________________________________________
2 personal references with phone numbers ____________________________________________________________________________________________________________________________________________________________________________________________________________
How did you hear about us?___________________________________________________________________________________________________
Please send in to
The
c/o Nicole Telkes
Applications are due after or upon initial
interview with a $265 deposit to hold your place