Three Treasures School of Traditional Chinese Medicine Certificate & Diploma in Tui-Na Massage ENROLMENT FORM Please attach a passport size photograph and send the completed form to: Three Treasures School of Traditional Chinese Medicine 60 Fore Street, North Petherton, Bridgwater Somerset TA6 6QA (PLEASE COMPLETE THE FORM USING BLOCK CAPITALS) Your First Name_____________________________________ Your Last Name_____________________________________ Title (Mr. Miss, Mrs, Dr etc)___________Date of Birth___/____/___________ Address_______________________________________________________ Post Code___________________Telephone No._______________________ Email address:__________________________________________________ Do have any previous experience or qualifications in massage and/or Traditional Chinese Medicine? Yes/No (please delete as applicable) If YES please enter a description below: Do you have any qualifications/ experience in Anatomy and Physiology? Yes/No (please delete as applicable) If YES please give information here: I have read and understood the details of the Tuina Certificate/Diploma Courses and am applying for a place on the following courses Course/s. Please state which course or courses: ______________________________________________________________ I declare that I am fit enough to perform both massage and Chi Gung exercises. . ______________________________ ______/ ______/ ___ (Signed) (Date)
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