To Register for Classes

For students registering for courses, please send this form with your check made out to the Institute of Qigong and Internal Alternative Medicine, or IQ&IAM, to:

IQ&IAM
P.O. Box 31576
Seattle , WA 98103.

Please call (206)301-0778 if you have any questions.

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The class for which you are registering: _______________________________

(Please indicate level, time, and location):____________________________

Payment amount:_______________________________ Check #:_________________

Name:___________________________________________________________________

Address:________________________________ email:_________________________

City:___________________________________ State: ________ Zip:___________

Home phone: _______________________ Work phone: ________________________ 

How did you hear about us?______________________________________________


To receive Continuing Education Credits please choose one option below;

IQ&IAM Certificate (CEU) ($15.00) ______________ (check paid to IQ&IAM)

Teacher CEU ($15.00)  _____________(check paid to The Heritage Institute)

CEU Payment of $15.00 can also be made at the class or seminar. The

Certificate or CEUs will be issued or mailed at the completion of the

course.


Signature: _______________________________________ Date:________________