Esalen Massage and Bodywork Association

Name_____________________________________________

Address___________________________________________

City_____________________State______Zip_____________

Country___________________________________________

Phone__________________Fax_________________e-mail_______________________ _

___ $50 Practitioner ___ $Donation to EMBA

___ Please do not list my name in the global directory

___ Please do not sell/rent my name/address

Please make your check payable to The EMBA. Funds are payable in US currency only. Do not send cash. Overseas residents must pay by checks drawn on US banks only, or use a credit card.

Charge my credit card: Visa ; M/C ; Amex (Circle one)

Expiration date:_______ Card # ____________________

EMBA MEMBERSHIP ASSESSMENT
Please attach a separate sheet answering
the following questions.
Where was your Esalen certification training held?
Who were the primary teachers?
What was the length of the training? Dates?
Number of hours on your certificate(s)?
Do you have additional Esalen massage/bodywork training hours? Please list and include dates.
Have you received certifications in any other forms of massage/bodywork? Please list
Are you a member of any other professional associations?
How would you characterize your practice?
What are your special areas of focus?

Yes, I will adhere to the EMBA ethical standards of practice.

Signature & Date _____________________________

Please enclose a photocopy of your Esalen Massage Certificate. We will provide you with an EMBA-approved seal via mail to attach to the original.