Scarwork Course Booking Form ScarWork Course Class Name* First Last Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Therapy Qualifications*Years of experience as a therapist (minimum 1 year and currently in practice required)Work Experience*Therapy QualificationsHow did you hear about the course?*Medical Conditions*Medical conditions we need to know about and scars you have on your bodyCOURSE AGREEMENT: I agree that Body in Harmony Training (BIHT) may hold my personal details and add my name to an email list in order to receive information/news on the subject of scars, other courses run by Sharon Wheeler, plus information on courses run by any of the accredited ScarWork tutors in the UK. I understand that my name and email will be available to all UK ScarWork tutors to provide me with information on post-grad courses and that I can unsubscribe at any time.*COURSE AGREEMENT: I agree that Body in Harmony Training (BIHT) may hold my personal details and add my name to an email list in order to receive information/news on the subject of scars, other courses run by Sharon Wheeler, plus information on courses run by any of the accredited ScarWork tutors in the UK. I understand that my name and email will be available to all UK ScarWork tutors to provide me with information on post-grad courses and that I can unsubscribe at any time. Yes No I consent to Body in Harmony Training adding my name to the email list to receive the monthly blog and course updates. I am free to unsubscribe at any time.*I consent to Body in Harmony Training adding my name to the email list to receive the monthly blog and course updates. I am free to unsubscribe at any time. Yes No I consent to the use of photos/videos (face not shown) taken on this course on social media or the BIHT website to promote ScarWork*I consent to the use of photos/videos (face not shown) taken on this course on social media or the BIHT website to promote ScarWork Yes No PLEASE TICK THE BOX TO CONFIRM THE FOLLOWING: I agree that no photos/videos made of my fellow students’ scars and range of movement etc. on my devices will be used in any public domain, eg website, social media, advertising, without the full, signed consent of that student. I will not share the photos/videos with anyone other than students on the course.*PLEASE TICK THE BOX TO CONFIRM THE FOLLOWING: I agree that no photos/videos made of my fellow students’ scars and range of movement etc. on my devices will be used in any public domain, eg website, social media, advertising, without the full, signed consent of that student. I will not share the photos/videos with anyone other than students on the course. Yes UntitledI agree that I will not take photos/videos of the members of the public (scar models) with my own device, only with their own if they wish. All other photos/videos will be taken by the tutor or teaching assistants.*I agree that I will not take photos/videos of the members of the public (scar models) with my own device, only with their own if they wish. All other photos/videos will be taken by the tutor or teaching assistants. Yes I will not replicate or distribute the materials from this course in any format whatsoever, nor will I share the private YouTube link to the first 9 techniques provided by Sharon Wheeler, and will respect that it is the copyrighted property of Sharon Wheeler, and elements are the intellectual property of Jan Trewartha of BIHT.*I will not replicate or distribute the materials from this course in any format whatsoever, nor will I share the private YouTube link to the first 9 techniques provided by Sharon Wheeler, and will respect that it is the copyrighted property of Sharon Wheeler, and elements are the intellectual property of Jan Trewartha of BIHT. Yes Please note – if required by government or common-sense guidelines, we will instigate precautions as needed to deal with any current virus situations. These may include masks, extra sanitising, and changes in how we run the class to reduce the number of people you are in personal contact with. If you have concerns about any of these precautions, please contact the tutor immediately so that we can discuss how best to accommodate you. Thank you for your cooperation.*Please note – if required by government or common-sense guidelines, we will instigate precautions as needed to deal with any current virus situations. These may include masks, extra sanitising, and changes in how we run the class to reduce the number of people you are in personal contact with. If you have concerns about any of these precautions, please contact the tutor immediately so that we can discuss how best to accommodate you. Thank you for your cooperation. I agree Δ