Application - Clinical Meditation and Imagery Date First Name*Last Name*Address*City*State*Zip*Home PhoneMobile PhoneEmail* How did you learn about this program?Professional degree*Do you have a current license or certification?*YesNoStateCurrent place of employmentPlease give us a brief description of the types of people you work with?*What has interested you in attending this program?*What are you hoping for in attending?*Please tell us what your experience has been with imagery and meditation. What is your personal interest and your professional interest?*Please submit this application with your $100 non-refundable application fee.*Pay with PayPalSend a checkPay with PayPal Price: $100.00 Please send a check made out to HMIC to: 2 Murray Court Huntington, NY 11743Tuition for the course is $1,795 and can be paid now with PayPal or later with a check.*Pay now with PayPalSend a checkPay now with PayPal Price: $1,795.00 Please send a check made out to HMIC to: 2 Murray Court Huntington, NY 11743PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.