Application
Advanced Learning and Development Institute
613 Bryden, 104
Lewiston, Id 83501
714-575-0001 866-812-7246
brainadvance@gmail.com
Parents’ Name_______________________________________________________
Client Name________________________________________________________
Address____________________________________________________________
City_____________________State_________________________Zip_ _________
Phone_____________Work Phone______________Cell Phone________________
E Mail:_____________________________________________________________
Clients age__________Areas of concern__________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Previous therapies ___________________________________________________
__________________________________________________________________
__________________________________________________________________
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Currently have or had in past:
_______sinus infection
_______frequent colds
_______swimmers ear
_______tubes in ears
_______plugged or hurting ear/s
_______allergies causing stuffed up nose or ears
_______itchy ears
_______tendency to wax build up in ears
_______hearing loss
_______ear infection (even 1-2 ever is significant)
Session attending, 1st choice:_____________________ (based on availability)
2nd choice for session _____________________
Deposit ______________ enclosed minimum deposit $2500 to accompany application, and $1000.total deposit $3500)Due at beginning of session, if approved for payment plan Otherwise full payment ($7900) due at first session. Master card and visa also accepted. Call for arrangements if payment plans are needed and for cost of your full program.. Discounts apply for early registration 6-9 months $500.00: 3-5 month $250.00.
CC:_____________________________________/Exp________
Signature_________________________________
Make Checks payable to Advanced Learning & Development Institute
Upon receipt of this application: Your acceptance will be confirmed and your registration paperwork sent to you.