Foundation Course Application
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First Name
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Last Name
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Email
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Title
Date of birth (dd.mm.yy)
*
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Ethnicity
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Prefer not to say
English/Welsh/Scottish/Northern Irish/British White
Irish White
Gypsy or Irish Traveller
Other White background: please describe below
White and Black Caribbean
White and Black African
White and Asian
Other Mixed/Multiple ethnic background: please describe below
Indian
Pakistani
Bangladeshi
Chinese
Japanese
Other Asian background: please describe below
British Black
African Black
Caribbean Black
Other Black/African/Caribbean background: please describe below
Arab
Other ethnic group: please describe below
Ethnicity - describe
Contact telephone number
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Street Address
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Town/City
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County/State
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Country
United Kingdom
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Australia
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Bahrain
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Bolivia
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Canada
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Chile
China
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Congo, Rep.
Costa Rica
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Italy
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Korea, Rep.
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Lao PDR
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Libya
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Malawi
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Monaco
Mongolia
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Morocco
Mozambique
Myanmar
Namibia
Nauru
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Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
St. Kitts and Nevis
St. Lucia
St. Martin (French part)
St. Vincent and the Grenadines
Sudan
Suriname
Sweden
Switzerland
Syrian Arab Republic
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela, RB
Vietnam
Virgin Islands (U.S.)
Yemen, Rep.
Zambia
Zimbabwe
Start date
*
December 2024
March 2025
June 2025
September 2025
How did you hear of this course?
*
A herbal practitioner
Web search
National Institute of Medical Herbalists
Herb Society
The Healing Garden at Emerson College
Social Media
Graduate
A friend
Other word of mouth referral
Other
Aming to join PC
No
I'm not sure
Yes
Are you intending to join the Professional Course after completion?
I am happy to receive pre-course materials at the email address indicated
*
Yes
I would like to reserve a place on the Heartwood Foundation Course on the date indicated
*
Yes
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