Name *

First Name

Last Name

Phone

(###)

###

####

I consent to my contact information being shared with my assigned partner for this 5 week clinic. *

Yes

I understand that it is my responsibility to collaborate with my partner and pre-book sessions online. *Please note that you will have ample flexibility anytime between regular clinic hours (Mon-Fri) except for stat holidays. *

Yes

I understand that I must commit to 10 sessions with my partner (ideally twice weekly) during my selected 5 week date range. *

Yes

In the event of illness, I will do my utmost to reschedule the session with my partner and provide advance notice. *

Yes

I agree to provide a testimonial upon completion of the clinic to be used for promotional purposes. *

Yes

I understand that a balance of $430 must be paid prior to the first clinic session and that this payment will be non-refundable. *

*Please arrange payment via email transfer to "Illya Borreson" info@aculoft.com

Yes