Application form

Name※

D.O.B

DD 　 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM 　 1 2 3 4 5 6 7 8 9 10 11 12 YY 　 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Address※

Tel.No.※

- -

Email※

Are you presently receiving any of the following:

Doctor’s care?

Yes No

The name of disease

Name, Address&Tel

Past aliment

Present aliment

Injuries, Operations

How did you learn about the Alexander Technique?

How did you hear about me?

I UNDERSTAND THAT AN ALEXANDER TEACHER IS NOT A DOCTOR OR THERAPIST AND DIAGNOSE, OR TREAT ANY SPECIFIC CONDITION.

Yes