We understand the potential sensitivity facing some of the questions below. This can be a very vulnerable area in your life. This information is valuable to us for knowing and understanding you better which enables us to make an educated determination about your attendance in the program. We strive to offer the most appropriate and best possible care & support for you. Please answer honestly. These questions and answers are strictly confidential and will be reviewed by our team only. Thank you so much! Are you attending as part of the MER Certification Training or for your own personal experience? Certification Training Personal Experience Are you an new student? New Student Existing Student Training SelectionSelect a training ...01.07. - 07.07.23 ~ Module 3: Poland14.08. - 20.08.23 ~ Module 1: France, Simiane La Rotonde24.09. - 29.09.23 ~ Module 2: Greece, Korfu27.11. - 03.12.23 ~ Module 3: France, Simiane La Rotonde08.12. - 14.12.23 ~ Module 4: Poland11.03. - 17.03.24 ~ Module 4: France, Simiane La Rotonde15.04. - 21.04.24 ~ Module 5: Poland02.06. - 07.06.24 ~ Module 5: Greece, Korfu06.07. - 12.07.24 ~ Module 6: Poland10.08. - 16.08.24 ~ Module 6: France, Simiane La Rotonde22.09. - 27.09.24 ~ Module 7: Greece, Korfu30.10. - 03.11.24 ~ Training: Poland11.11. - 17.11.24 ~ Module 7: Poland02.12. - 08.12.24 ~ Module 1: France, Simiane La Rotonde28.03. - 03.04.25 ~ Module 2: France, Simiane La Rotonde25.05. - 30.05.25 ~ Module 3: Greece, Corfu11.08. - 17.08.25 ~ Module 4: France, Simiane La Rotonde12.10. - 17.10.25 ~ Module 5: Greece, Korfu24.11. - 30.11.25 ~ Module 6: France, Simiane La Rotonde Personal DetailsName* First Last Gender* Male Female non-binary Email* Enter Email Confirm Email Phone*Country*Select a countryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweDate of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Place of birth* ExperienceHave you ever taken any massage or body work trainings?*Why MER?*Please share why you are interested in joining the MER event.What do you hope to take away from attending this event?* Medical QuestionsDo you have any chronic pain in your body?* No Yes Please tell us about your chronic pain!*Have you ever been under the care of a Psychologist or Psychiatrist in the past?* No Yes Please provide the details of the nature for this care. For what specific purpose? For how long? The results? Any other relevant information.*Are you currently under the care of a medical doctor?* No Yes Please provide the details of the nature for this care.*Are you currently taking any medications?* No Yes If yes, please list the names and what for. For example blood pressure, anti-seizure, asthmatic or COP inhaler* Final Questions and CommentDo you need an invoice?* No Yes Which address should be added to your invoice? Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman 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 How did you find us?*Please selectThrough a friendProfessional referralWeb SearchFacebookYoutubeInstagramWebsite linkOtherMay we ask further?You don't need to answer this but it would be great for us to know about your web search. What did you search for and did you use Google or another search engine?Add a message if you wish.HiddenTerms and Confidentiality AgreementPlease read our Terms and Confidentiality Agreement I agree Please double-check your input and submit the form. {all_fields}NameThis field is for validation purposes and should be left unchanged.
