Ancestral Apothecary Summer and Fall 2018 Courses Application
Deposits of $100 are required to save your space in a class. For shorter-term classes, full payment is required to save your space in the class. *We are not doing payment plans at this time. If the class becomes full- we will add you to the waitlist in the order you submit your application. Deposits are refundable ONLY if you cancel more than one month before the first day of class or if class is canceled.

Payments can be made by:

Paypal/CC: https://www.paypal.me/AncestralApothecary (Please include 3% to the total of what you will be paying for paypal fees.)

Check: made out and mailed to: Ancestral Apothecary 3798 Grand Avenue Oakland, CA 94610

*FOR Retreats, full payment is due 30 days before before class.

*** If you have taken a class with us in the past-- please fill out your name and *only the information that needs to be updated (PLEASE write N/A in the sections that don't need to be updated)


Full Name *
Past Student? *
Class(es) you are applying for *if applying for multiple classes please indicate your other class in the "Other" line *
Email Address *
Phone Number # *
Date of Birth *
MM
/
DD
/
YYYY
Emergency Contact Info *
Name, Relationship, Phone #
Mailing Address (Home) *
Address, City, State, Zip
Do you have any medical or accessibility needs that we need to know? *
Prefered gender pronoun
Racial/cultural/ethnic background
For the purposes of creating a safe space for the group, in what other ways do you self-identify that you'd like to specifically and explicitly let us know?
What is your background, if any, in holistic medicine, herbalism, curanderismo and/or ancestral medicine? *
What interests you about this class? *
What is your intention for this class or what do you hope to achieve? *
Anything else we should know about you?
How did you hear about the class? *
Any questions for us?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy