Workshop Registration Form

Your answers to this registration form are confidential and will only be seen by teachers and staff.

Name

First Name

Last Name

For which workshop are you registering?

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Name of emergency contact

First Name

Last Name

Emergency contact's relationship to you

Emergency contact's phone number

(###)

###

####

How did you first learn about Rosen Method?

How did you hear about this workshop?

What is your purpose in taking this Rosen Method workshop? What appeals to you about attending this workshop?

What is your profession?

Have you received Rosen Method bodywork sessions? If so, how many? Name the practitioner.

What forms of self-care have you previously practiced, or are currently practicing? For example, have you received other forms of bodywork, studied other forms of movement, participated in human potential or self-awareness trainings, practiced meditation, or participated in psychotherapy? Please specify.

Is there anything else you would like us to know about you?

When being addressed, what pronouns do you prefer?

She/Her

He/Him

They/Them

Any of the above

She/They

He/They

Other (please specify in box above)

Please sign and date this registration form.

Your digital signature confirms that you have completed this form accurately and honestly, and that you have reviewed our cancellation and refund policies.

First Name

Last Name

Date of signature

YYYY

Would you like to receive information about future Rosen Method Open Center events?

Yes

Thank you for your interest in this workshop. The teachers of the workshop will call you to discuss the details of the workshop upon receipt of your registration.

Please refer to the RMOC website for our cancellation/refund policy.