Application Form

Application Form

return to or by post to either

Dave Wassermann, Os Figueiros, Canezac, 81190 Montirat, France

or Miriam Rose, 34 Hunters Moon, Dartington, Devon TQ9 6JT

Contact details

First name






Emergency contact number
Date of birth
Sex M F (‘star’ appropriate letter)

Occupation (optional)

How did you hear about us ? (optional)


It would be helpful for us to know a bit about you, what are you particularly interested in and what you are hoping to find on this course. Do you have any previous experience? (As little or as much as you want to write)

Due to the nature of the holiday, intense feelings can arise. So we would like to know a bit about your health in advance. Any information you give us is completely confidential.

Is there any major physical or emotional illness you think we should know about?

This holiday does not provide individual therapy but intense feelings may arise. So if you have any major emotional or mental health issues please check with your doctor that this course is suitable for you. And please consult us if you are unsure about this or need any further advice.

I have read the course details on the website and am happy with the information provided about the course. By returning this application form I am agreeing to the programme and conditions outlined on the website and above

Please insert Name and Email Address and sign if returning by post

How would you like to pay?

(please put  symbol etc by appropriate word)

Euros  /  Pounds

Cheque / Bank Transfer

Deposit  / Full balance

Single room / Shared room

The supplement for a single room for the week is £85 /100 euros.
£570 or 680 euros standard booking to be paid by 15th July
£480 or 580 euros early booking to be paid by 15th May

In order to reserve your place we require a deposit of £125 / 150 euros (per person) or full payment if it is less than 4 weeks away from the start of the course.

On receiving your application we will send you an email confirmation and details of how and when to pay.
Just in case of any technical problems, if you don’t receive a reply within 7 days please contact us again.
Best Wishes
Miriam, Carmen and Dave

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