Course Enrollment Form

Please fill out this form and return all pages with payment

To: MIM

P.O. Box 413

Sedona, Az 86339

Name: _______________________________________________

Mailing address: _______________________________________

City_________________ ____________state_______zip_______

Home phone:(_____)____________

Day phone: (_____)____________

e-mail_____________________________

Date of birth__________________ age__________

Please check next to the Intensive you wish to attend and enter the date below.

__MIM level I __MIM level I I __MIM level I I I

Enter the date and location of the course you wish to attend_____________

Please read note at end of form for requirements for each course.

Cost for weekend course is $222.00.

Please make payments to : Wanda Zum Mallen

Please check if you have knowledge or training in any of the following

__ Energy Theragy __ Beginning Psychology __ Beginning Physiology

__ Beginning Anatomy __ Chakra and Aura scanning __ Massage Therapy

Please check next to your highest level of education: __ High School __ Technical School __ College

Please describe any other training you have had that is not listed:_____________________________________________
_________________________________________________________________________________________________

_________________________________________________________________________________________________

Please give a brief description of why you wish to attend this intensive and what you expect to receive from it:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Please return both forms with payment two weeks prior to the date of the Intenstive wishing to attend. A $100 dollars of your course fees will be returned if you cancel anytime prior to the start of class. Space is limited and seats will be filled as registrations are received.

Note:

Requirements:

MIM level 1 NO requirements, just have an open heart and mind.

MIM level 2 Have completed MIM level 1.

MIM level 3 Have completed both level 1 & 2 courses.