CSHT Student Intake Form

Student Intake Form
Welcome to Chelsey Sturgeon Holistic Therapy Training School.

This is a safe space for everyone and it is my mission to make sure you feel included in every aspect of your learning.

Your data is used only for the purposes of providing support to you on your learning journey.

All data is managed in accordance with GDPR.
Student Name*

First NameLast Name
Course Name:
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Student Email Address*
example@example.com
Home Phone Number

Area CodePhone Number
Mobile Number

Area CodePhone Number
Please describe any learning support needs you have eg. Dyslexia, Hearing loss, Sight Loss, Neurodivergence *
Please describe any reasonable adjustments we can consider to assist with your learning *
Student Electronic Signature*

Clear
Should be Empty: