2016/17REGISTRATION FORM

Year 1FOUNDATIONS classes

“TWO WEEKS X 2”alternative schedule

Bandera, TX

Sponsored by an Approved Eden Energy Medicine Foundations Classes TeacherEva Gold,CNHP,EEM-AP

Eden Energy Medicine Advanced Practitioner and Teacher

,

Eva’s home address: 194 Delaware Ave., Toronto, ON, M6H 2T3, Canada

Cell: 416 575 2806, whatsapp and viber options

Eva’s teaching address in Texas:

Silver Spur Guest Ranch, 9266 Bandera Creek Road

Bandera, TX, 78003

Texas Office: 830-796-3037

The Eden Energy Medicine Foundations Classes in Bandera, TX is a one-year program designed for those people desiring in-depth coursework and supervision in Donna Eden’s style of Energy Medicine ( This program is based on a curriculum developed by Donna, along with her faculty members. The goal of the program is to help any student of Eden Energy Medicine obtain a firm foundation in the body of work Donna has created over the past 30 years and to develop the skill levels necessary tobegin using these techniques regularly, either with family and friends, or in a professional setting.

Successful completion of the Foundations Classes in Bandera, TXwill give students the option of applying this class work toward Year 2of the Eden Energy Medicine Certification Program held in Phoenix, Arizona. Completing Year 2 is optional; students in the FoundationsClasses may feel satisfied after one year and not see a need to take their studies further. At the end of the one-year Foundations Program, students will receive a certificate stating they have completed the Foundations Program in Eden Energy Medicine, but this should not be construed as a certification in Eden Energy Medicine, as that requires the completion of the Year 2 program.

The main purpose of the Foundations Classes is educational and classes will include lecture, small group time for practice, as well as question and answer sessions. Each class is designed to provide you with skills for working with the body's energies to promote physical and emotional well-being. This can be an intense experience, and doing energy work in a large group can be taxing, so if you are not in good health we ask you to take this into account before registering. If your primary need is in pursuing a healing experience, we encourage you to contact one of the trained practitioners listed on Donna Eden’s website and work with them directly.

The Foundations Classesin Bandera, TXwill be taught by Eva Gold(CNHP, EEM-AP) and

Laurel Camden(EEM-AP).

Eva Gold(CNHP, EEM-AP)is an Advanced Eden Energy Medicine therapist, authorized Energy Medicine for Women instructor and one of the Faculty Members of the Eden Energy Medicine Certification Program in Phoenix, AZ. She is also a Licensed Natural Health and Medical Qi-gong Practitioner, Reflexologist, and a Clinical Aromatherapist.

Laurel Camden (EEM-AP) is an Advanced Eden Energy Medicine practitioner and a Faculty member of the 4 yearEden Energy Medicine Certification Program basedin Arizona. She teaches Year 1 Foundations classes in regional areasand Years 2-4 in Arizona. She is also an authorized instructor forEnergy Medicine for Women and EEM101 & 102 classes.

“TWO WEEKS X 2”Special Option with an alternative schedule

Imagine immersing yourself in two weeks of fluid practice and learning the Foundations .

This exceptional option is designed for students who want to travel only twice to take all four classes.Foundations classes 1 and 2 will be taught within 13 days of August and will fully cover the EEM materialand provide an excellent opportunity for independent practice and studies.Class 1 and 2 written exams will be administered on site. The same will apply to class 3 and 4.

Foundations classes 3 and 4 will be taught within 13 days of Jan./Feb. 2017.

All classes must be taken in sequence. Each of the preceding classes is a prerequisite for those that follow.

Question for Laurel

What are options available if student cannot make all the classes. Do we need to adjust our Withdrawal Policy?

2016

Class 1 & 2: August 14 - 26, 2016

Class 3 & 4: January 22 – February 03, 2017

All classes will start at (times of classes)

Sunday: 5:00 PM – 9:00 PM orientation

Monday – Thursday 9:00 AM – 5:00 PM

Friday: 9:00 AM – 1:00 PM

There will be breaks and time off for lunch. This schedule may vary slightly if unforeseen needs arise.

Where: Silver Spur Guest Ranch, 9266 Bandera Creek Road

Bandera, TX, 78003

Texas Office: 830-796-3037

Tuition in US Funds: $3980.00 per year ($995.00 per class). The tuition paymentscan be paid in full or bi-yearly - one month prior to each class. The tuition covers all of the class handouts, conference space, faculty, and continued supervision by the teaching staff for the duration of the program. The cost of tuition is guaranteed for the current year.

Please make post dated checks payable to:Eva Goldand mail to

194 Delaware Ave., Toronto, ON, M6H 2T3, Canada

Accommodations:Meals and lodging are at the student’s expense.

Call830-796-3037 for accommodation package at the Silver Spur Guest Ranch.

Your all-inclusive package includes:comfortable accommodations, healthy meals, snacks, and beverages, massage tables and use of ranch amenities and activities. (Horseback riding and Healing Studio sessions are discounted to students) Accommodations are per person per night and rates are as follows. Single occupancy $135, Double $105 and $97.25 for 3+ to a room. $100 deposit is required at registration and balance paid in full prior to class. Space is limited as there are only 15 rooms and cabins, however, many sleep up 5 - 8 per room. Check out rooms and cabins on line;

On site reservations are booked on a first come, first serve basis. For commuters, a daily package includes massage table, meals and snacks $75 per day. Local hotels are about 10 miles away if you prefer to stay offsite.

Due Dates:

Total tuition for all four classes is $3,980 USD

The payments are broken into two installments.

Class 1 and 2: payment due July 14, 2016 in USD $1,990.00

2 x 995.00 (deposit of 300.00 US was applied to class 4 tuition)

Your non-refundable deposit of $300.00 USD submitted upon registration will be applied to class#4.

Class 3 and 4: payment due Dec. 22, 2016 in USD$1,690.00

Eden Energy Medicine Certification Program (EEMCP): If you are interested in applyingyour year in the FoundationsClasses in Bandera, TXtowards becoming certified in Eden Energy Medicine, there are several items to consider.

  1. The Year 1 Foundations Classes is designed for students interested in applying Energy Medicine to themselves, friends, and family. Students who complete Year 1 will receive a Certificate of Completion.There will not be a title associated with the certificate and students will not be listed on the Innersource website as an EEM Practitioner. Students are eligible to attend Year 2 of the EEMCP program within two years following completion of
    Year 1.

If students who complete Year 1 also complete Year 2 of the Certification Program, they will be entitled to use the title Eden Energy Medicine Certified Practitioner (EEM-CP) and be listed on the Innersource website as such. The Year 2 EEM Certification Program is recommended for students who plan on applying the energy methods professionally or who want to heighten their proficiency. The requirements for each program are outlined on Innersource’s website.

2. Both the Year 1 Foundations Classes and the Year 2Certification Programrequire you to complete a take home, open book test after each quarter and do a live or Skype demonstration of the material learned.

3. All students must pay a $300.00 US (or an equivalent according to the exchange rate policy for the particular due date) non-refundable deposit (submitted toEva Gold), along with their registration form for the Foundations Classes. This deposit will be applied to your Class 4 tuition.

4. Before taking Certification classes in Phoenix, please read the guidelines from Innersource that outline the steps you need to take in order to become registered:

Continuing Education:

Year 1: Innersource is approved by the following organizations for Continuing Education credits for all classes that fall under the Eden Energy Medicine Foundations Classes.

American Holistic Nurses Association (AHNA)

  • 104 Nursing Contact Hours (CH's) to be awarded upon completion of the four-
    class course.
  • Cost $50
  • This continuing nursing education activity was approved by the American Holistic Nurses Association (AHNA), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation (COA).
  • Approved through June 20, 2017.
  • Approval for contact hours through the AHNA is based on an assessment of the educational merit of this program and does not constitute endorsement of the use of any specific modality in the care of clients.
  • To view the requirements for successfully completing this program in order to receive CNEs, the purpose statement, and the educational materials used in this program, please visit the Innersource website:

Association for Comprehensive Energy Psychology (ACEP)

  • 26 ACEP CEs per class
  • No fee for these CEs. The student uses the Certificate of Completion provided to them at the end of Year 1 to show proof of CEs to ACEP.
  • Innersource is an ACEP CE Provider.

California Board of Behavioral Sciences (CA BBS)

  • 26 CE Credits per class
  • Cost $50
  • Innersource is an approved to offer continuing education for MFT, LPCC, LEP, and LCSW licensure requirements in California (PCE 5055).

National Certification Board for Therapeutic Massage and Bodywork (NCBTMB)

  • 26 Contact Hours (CHs) per class
  • Cost $50
  • Innersource is approved by the National Certification Board for Therapeutic Massage & Bodywork (NCBTMB) as a continuing education Approved Provider.
    (Provider number: 450052-06)

Southern Oregon University (SOU)

  • 10.4 Continuing Education Units (CEUs) per class
  • Cost $50

Year 2:If you register for the Year 2 Eden Energy Medicine Certification Program, CEs will be provided upon completion of all Year 2 classes in Phoenix. The following CEs are available:

Innersource is approved by the following organizations for Continuing Education credits for all classes that fall under the Eden Energy Medicine Certification Program.

American Holistic Nurses Association (AHNA)

  • Innersource is currently working on approval for Year 2 of the EEMCP for AHNA CNEs. We will update this information when approved.

Association for Comprehensive Energy Psychology (ACEP)

  • 26 ACEP CEs per class
  • No fee for these CEs. The student uses the Certificate of Completion provided to them at the end of Year 2 to show proof of CEs to ACEP.
  • Innersource is an ACEP CE Provider.

California Board of Behavioral Sciences (CA BBS)

  • 26 CE Credits per class
  • Cost $50
  • Innersource is an approved to offer continuing education for MFT, LPCC, LEP, and LCSW licensure requirements in California (PCE 5055).

Energy Kinesiology Association (EnKA®)

  • Upon completion of Class 8, you may use the 243 EEMCP hours towards EnKA Certification.

National Certification Board for Therapeutic Massage and Bodywork (NCBTMB)

  • 26 Contact Hours (CHs) per class
  • Cost $50
  • Innersource is approved by the National Certification Board for Therapeutic Massage & Bodywork (NCBTMB) as a continuing education Approved Provider.
    (Provider number: 450052-06)

Southern Oregon University (SOU)

  • 10.4 Continuing Education Units (CEUs) upon completion of the Foundations Year
  • Cost $50

If you have any questions as to whether or not your professional continuing education requirements can be met through completion of this program, contact your professional licensing organization or state professions’ bureau for a final decision.

Class Materials: All students must purchase the following class materials BEFORE Class 1 starts:

Energy Medicine book by Donna Eden

Energies of Love DVD (not required if they attended this “live” class with Donna and David or if you bought the recent book”Energies of Love”)

Ethics Handbook for Energy Healing Practitioners

The Nine Energy Systems DVD

We request that you bring your Ethics Handbook for Energy Healing Practitioners and Energy Medicine book for reference at each class.

Please order these materials online at

Registration Procedures:

Please fill out and send in (via a regular mail) the attached registration form, along with your non-refundable deposit of $300.00 USD. We will process it and notify you via email that you are registered. Early registration is suggested as space may be limited.

Please make your non-refundable deposit checkor USD money order payable toEva Gold and mail it with your registration forms to the address provided below:

194 Delaware Ave., Toronto, ON, M6H 2T3, Canada

The Eden Energy MedicineYear 1foundations classes 2016:

Bandera, TX, 78003

Begins: August14-26 Early registration suggested.

Sponsored by: Eva Gold (CNHP, EEM-AP)

ApprovedEden Energy Medicine Foundations Classes Teacher

Name ______

Address ______

City ______State ______Zip ______

Please provide all phone numbers, if available. Note which phone # we can use for the student roster.

Home______Work______Cell______

Email (print clearly) ______Profession?______

How did you hear about the program? ______

What experience do you have with energy work?______

Your contact information will not be sold or distributed to third parties. Innersource will send you information about training opportunities.

A student roster will be available with Name, Phone & Email for our class: Do Not Include Me

OPTIONS: Please select which box best fits your intention. (This is not binding - students may change their mind. This is meant to help with Innersource’s planning only.)

My intention is to enroll in the Year 2 EEM Certification Program

My intention is to attend the Year 1 EEM Foundations Classes only

 I will be applying for CEs ($50.00 to be paid when registering at Class 1)

PROGRAM COSTS

Tuition: Full amount for Year 1Foundations Classes is $3980.00 USD

Class 1&2: 2X $995.00 + $300.00 US Due July 14 / 2016

Class 3&4: 995.00 + $695.00 **USDue Dec. 22 / 2016

**Note: You pay a $300.00 US non-refundable deposit when you register. It is applied to your
Class 4 tuition. See payment schedule below.

Payment Option
Deposit
___$300 USD non-refundable deposit required
with registration form.
(or the equivalent according to the current exchange rate in CAD)
Please check below which of the payment options you plan on using for your tuition.
Tuition Cost in USD (Check one)
 $3,980 USD for the full year
 $1,990 USD for ½ of the year
$50 USD for each type of CE
***************************************************
in USD
$ 300.00Deposit ($300.00) due uponregistration
$ ______Tuition due by July 14 2016
$ ______CEs (if applicable)
$______Total Payment / Payment Method
check
money order
interac deposit
______
Signature Date
Check Enclosed, payable to Eva Gold
Amount: $______
Check #: ______
Due dates are:
Class 1&2: July 14, 2016
Class 3&4: Dec.22, 2016
I commit to attending both 2X2 clesses

Signature:______Date:______

By my signature, I affirm that I have:

1)read and understand the Eden Energy Medicine Foundations Classes–Bandera, TX 2016/2017 Information Form, including class dates, due dates for 1) payment and 2) competency tests (written and live/Skype demo), and associated late fee policy.

2)read and agree to the withdrawal policy, missed class policy, and release agreement included with the Registration Form.

Please mail to:

Eva Gold, 194 Delaware Ave., Toronto, ON, M6H 2T3, Canada

Contact Information: 416 575 2806

whatsapp and viber options

Eden Energy MedicineYear 1Foundations Classes:

Bandera, TX

Eva Gold and Laurel Camden

Approved Eden Energy Medicine Foundations Classes Teachers

WITHDRAWAL POLICY

Prior to Class 1 and 2:

Students who withdraw from the program up to 60 days prior to the start of Class 1 and 2 will receive a full refund, less a $50 US administrative fee. For withdrawals between 30 and 60 days prior to the start of
Class1 and 2, $300deposit US will not be refunded. Payment for the first class is due on July 14, 2016. Due to limited space and other commitments we have to make well in advance in planning such events, no refunds can be made for withdrawals received within 30 days of the start of Class 1 and 2.

Emergency withdrawals will be handled on a cases-by-case basis.

Year 1FOUNDATIONSCLASSESRelease Agreement

I understand that Eden Energy Medicine is an innovative approach to health care, which is only beginning to be investigated scientifically. I further understand that the training in Eden Energy Medicine and other services I am or may be receiving from Eva Gold/Laurel Camden/Innersource do not substitute for diagnosis and/or treatment from a qualified health practitioner for illnesses, injuries, or other medical conditions.

I understand that some classes are videotaped, that these tapes may be distributed for educational purposes, and I give my permission for my participation to appear on these tapes.

Eva Gold/Laurel Camden/Innersource \reserves the right, at its discretion and without explanation, to ask a student to leave an Eden Energy Medicine Certification Program Year 1 class, to terminate a student from Year 1 of the EEM Certification Program, or to not complete a student from Year 1 of the EEM Certification Program based on failure to meet the academic, behavioral, professional, or ethical standards of the program as determined by Innersource staff. Any refunds will be fairly determined, again at the discretion of Innersource staff, on a case-by-case basis.

I also understand that any activity in which a person might participate involves some risk. In consideration of being permitted to enroll for the instructional and other services offered through Eva Gold/Laurel Camden/Innersource, I release and hold Eva Gold/Laurel Camden/Innersource, its agents, officers, employees, directors, successors, and affiliated corporations harmless from any claims arising out of my participation in the instructional or other services offered by Eva Gold/Laurel Camden/Innersource.

Student Signature: ______Date:______

Printed Name: ______

Please keep this information handy so you can refer back to it
once we get closer to the class dates.

‘RELAX AND ALLOW’