New Student Registration Form

Thank you for registering!

SoHA & Awareness Studios
6255 Barfield Rd. Suite 110 • Atlanta GA 30328
(404) 257-1257 • www.SoHAonline.org

Name *
Name
Phone *
Phone
country code (not required within the U.S.)
Address *
Address
Birthday *
Birthday
Would you like to be on our mailing list?
Where were you born? Were your parents together? What is your position in the birth order? Step siblings? Half-siblings? Parents still together? Deceased? Divorced? (If so, how old were you?)
Do you have any children? With current or past partner, or both? What are their ages?
Lineage and Cultural Background (ethnicity, religion, parental nationality...) Maternal and Paternal
Have you ever done a DNA test? [i.e., 23andMe.com, or Ancestry.com] If so, what were the percentages of the different cultures/ethnicities represented?
What illnesses or surgeries have you had? When did they occur and what was the treatment? [This information is confidential.]
Are you currently on any medications? Which ones? [This information is confidential.]
Informed Consent *
I understand the course/sessions are educational and for detoxification, and not a substitute for psychotherapy or medical treatment. I assume the risk, by this consent, of any illness or injury during or after the session/course/detox treatment, and hereby release the School of Humanity & Awareness, Inc and Awareness Studios, LLC, Vibrancy, LLC, Sukhhavatia, LLC, and/or Apollonia Fortuna from any and all liability.
Cancellation Policy *
SESSIONS *24-hour notice of cancellation for scheduled appointment is required (except in emergency) to avoid full charge for the session. COURSES * If you cancel your attendance more than 1 week before the course date, your tuition will be refunded, less the deposit. The deposit may be rolled to your next course registration. * If you cancel your attendance less than 1 week prior to the course date, your entire tuition will be forfeited. An exception to this policy will be made if you are hospitalized or if you are attending the funeral of a member of your immediate family.
Signature *
Signature
By typing my name in the box below, I am acknowledging that I am at least 18 years of age and have read and agree to the Informed Consent and Cancellation Policy above.
Today's Date *
Today's Date