Class Registration Form All Classes

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**If you have filled this out recently for another class, you do NOT need to fill it out again unless you have updated info to share.

Current Class Offerings:

Biodynamic Approach to Craniosacral Therapy, Part 1 (starts Apr 18, Thurs 9am-12pm)
Healing Arts and Ethics (April 21 & 28, Sun 2-5pm)
Exploring the Vagus System Part 2 (June 22-24, 2024 In person Weekend)
Exploring the Vagus System Part 3 (Nov 9-11, 2024 In person Weekend)
Exploring the Vagus System Part 1 (starts Sept 16, Mon 2-5pm)
Exploring the Vagus System Part 2 (starts Nov 4, Mon 2-5pm)
Exploring the Vagus System Part 3 (starts Feb 3, 2025, Mon 2-5pm)

Birthing Yourself Process Workshop (use this form instead)
PPN 2-Year Study Group by Zoom (use this form instead)

Janet Evergreen, MA
115 RiverBluff Circle, Charlottesville, VA 22902
(434) 906-4181
janet@janetevergreen.com
www.janetevergreen.com

For more information about classes and where they will be located, please visit the
Classes page on Janet's website.

Email *

Course Title: *

Course Date/Time: *

Name and Credentials (as you wish to appear on your certificate) *

Address: *

Telephone Number: *

Communication Preferences: *

Check if you text message.

Check if you are willing to share your phone and email contact with your class.

Required

Birth Date and Age: *

Familial Status (i.e. married, partnered, single, divorced, children, grandchildren...) *

Emergency Contact Person and Phone Number: *

Are you a bodyworker who would like to receive NCBTMB continuing education credits?

(If yes, we will send you the appropriate form.)

yes

Class Agreements *

I understand this is a somatic-based teaching and experiential inquiry. I will take responsibility for my own mental health and wellbeing during retreat.

I agree to uphold confidentiality for this group.

Required

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