Dr. AfrikaReg

Holistic Health Volunteer Registration. Holistic Health students are required to submit health assessments to receive the Holistic Nutritional Counselor Certification. Complete this form to receive a FREE health assessment. Available in the Tulsa area only.

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Date of Birth *

Are you Local (Tulsa) or out of town? *

local Out of town

If out of town, what city or state? *

Explain Food Allergy. *

If other, explain? *

If known, how do you plan to use the information learned in this class? *

Heal yourself Help with family health Provide counseling to your community other

Other/ Explain *

Are you interested in a study group for the class? *

Yes No

Remember, your registration is not complete without a payment.
After submitting this form, click the "add to bag" option on the next page before April 10, 2015 for the
discount.
If you are making a payment less than the full discounted amount, mention so in the comment section below. Submit the form, click on the "donate" button near the bottom of the next page.
Enter amount and pay via paypal or your credit/debit card.

You do not have to sign up for paypal to pay with a card.

Comments/ Questions *

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