Registration & Agreement for Practicum at Whidbey Institute
With Integrative Mental Health University

Please copy the full document, fill in and email back to [email protected]
Personal Information
Name: ____________________________________
Address: ___________________________________
Phone (H): ______________________________
Date of Birth: __________________________
Dates of Course: _______________________
City/State/Zip: _________________________
Email: ___________________________________
Preferred Pronouns: ____________________
Cell phone: _________________________________________________________________________
How did you hear about this course? __________________________________________________
Accommodation Preferences
Preference for type of room: _______________________________________________________
Preference for room-mate / Single room: _____________________________________________
If sharing a room - preference Queen bed or Separate beds: _________________________
Special needs (e.g. wheelchair): ____________________________________________________
Dietary restrictions: ________________________________________________________________
Emergency Contact

Name: ___________________________________
Relationship to you: ____________________
Phone number: _________________________
Email: ___________________________________
Professional Information & Prerequisites
Do you have a role as a healthcare provider or spiritual guide? _______________________
Do you want CE credit hours? If yes, for which license? ___________________________
Pre-requisite course info: "How to Effectively Support Someone in Spiritual Emergency" with link to https://courses.imhu.org/courses/how-to-effectively-support-someone-in-spiritual-emergency
What is your motivation for taking this Practicum? ____________________________________

Pay deposit online or send check to: "Foundation for Energy Therapies, inc."
Emma Bragdon, PhD., Exec. Director
8 Clough Ave, Windsor, VT 05089, USA
Landline: 802-674-2919
Agreement with Foundation for Energy Therapies, Inc. Regarding Practicum at Whidbey Institute
Responsibility
The Operator of this Practicum at Whidbey Institute is Foundation for Energy Therapies, Inc. a 501(c)3 non-profit educational organization. Dr. Emma Bragdon and Andy Johns serve as Co-Executive Directors.
Liability
By registering for this Practicum, the Participant agrees to limit the liability of Foundation for Energy Therapies, Inc. and Integrative Mental Health University to the fees paid for the Practicum.
Accommodations, Changes & Meals
Roommates policy: Each participant is responsible for finding their own roommate. If you request a roommate, we will help you connect with others seeking roommates.
Changes or Cancellations policy: All changes or cancellations must be submitted in writing. Specific deadlines apply for partial refunds, as outlined in the refund policy below.
Meals: Twelve meals are included in the Practicum fee (three per day during the main program dates). Special dietary restrictions should be noted in the accommodation preferences section.
Tips and Extra Donations: Both Foundation for Energy Therapies, Inc. and Integrative Mental Health University are 501(c)3 charitable organizations. Tips for staff are appreciated, and additional donations are tax-deductible to the extent permitted by law.
Payment Schedules & Refunds
Initial deposit: $500 (non-refundable)
Total payment due: August 1, 2025
Earlybird pricing deadline: February 1st, 2026
Payment address and methods:
  • Send check to "Foundation for Energy Therapies, inc." (Address above)
  • Wire transfer details available upon request
  • PayPal option available online
Refund Policy
The $500 initial deposit is non-refundable. For cancellations received before July 1, 2025, a 50% refund of the remaining balance will be issued. No refunds will be given for cancellations after July 1, 2025. We strongly recommend purchasing trip cancellation insurance to protect your investment in case unforeseen circumstances prevent your attendance.
Participants & Medical Responsibility
Participants are expected to adhere to all program guidelines and regulations set forth by Foundation for Energy Therapies, Inc. and Whidbey Institute.
Each participant assumes full medical responsibility for their health and well-being during the Practicum. It is recommended to consult with your physician regarding any health concerns prior to participation.
Today's Date: ____________________________________________________________________
Legal Signatures
______________________________________________
Foundation for Energy Therapies, Inc.
By: Emma Bragdon, Co-Exec. Director
______________________________________________
Participant Printed Name

To reserve your space, please sign and date this agreement, then email or mail the full document back to [email protected].
Full Balance Due 7 days prior to course start