Reconnecting With Nature: Personal
Balance Course
Application Form
INSTRUCTIONS: Highlight copy
and paste this form into an email
to our office.
This form may also be obtained by email from an automailer; simply
send the blank email to you get in your email program by clicking
here: balanceapplic@aweber.com
Complete the form and return/send it to nature@interisland.net
TO: Department
of Applied Ecopsychology/Integrated Ecology
I am familiar with the Personal Balance Course description and am applying to
enroll in the ten-week online course for the following fee:
FEE: Select
below A. B.
or C.
A. ( ) regular student
$290.00
B. ( ) Financial Assistance
Student: $290 with financial assistance based on financial need
(call 360-378-6313 for information)
C. ( ) Included as one of the seven courses for Level
One Certification
($740 total prepaid)
Your name:_________________________________
Email Address:
Website URL if applicable:
Postal Address:
City, State, Zip:
Telephone:
Occupation or major interest:
How or where did you hear about
the course?
The course starts at the beginning
and middle of each month or by
convenient dates for 4 or more participants and a facilitator.
My preferred dates to take
course:
First Choice Date: Month _______
Day ________ Year________
Second Choice Date: Month _______
Day ________ Year________
Third Choice Date: Month _______
Day ________ Year________
Course Instructions
and Readings:
The course
fee of $290 includes the
two books, Project NatureConnect and The Web of Life
Imperative, supplementary email material and all aspects
of the guided ten-week Project NatureConnect Personal Balance
Course. If you decide to continue on with academic, professional
or personal training in this work, you can apply $200 of the
course fee to study in the Certification
Level One program.
ADDITIONAL PROGRAM PLANS:
( ) YES ( )NO Are you presently
interested in continuing on with the Orientation
Course Psychological Elements of Global Citizenship course
(1 credit optional) ?
( ) YES ( )NO Are you presently
interested in the certificate or degree program?
http://www.rockisland.com/~process/
( ) YES ( )NO Do you want to
obtain transferable credit for this course from Portland State
University (PSU)? (It is optionally available for $47.00 above
the course cost and may be arranged upon completion of the
course.)
NOTE: IGE affiliated university
degree program students should ordinarily not apply for Portland
State University credit. They automatically obtain credit for
this course in their IGE program upon Degree Program enrollment
. They do NOT need to apply for PSU credit nor pay extra for
it.
INTRODUCTORY STATEMENTS
1. By way of introduction,
please share with us in less than 400 words, a good experience
that you have had with nature as a child or adult. What do you
think, feel or sense about that attractive experience?
2. As a helpful prerequsite
for this course please visit the Project NatureConnect web
site. Then respond to the paragraph below in the light of
the information available on the web site.
Write approximately 350 words
(or less) about your background and why you want to take this
course. Retain a copy of your statement as you can use it to
introduce yourself to your email classmates. You may modify it
for that purpose if you choose.
Email all the above and below
information to nature@interisland.net
and save a copy of it for use in introducing yourself to your
classmates on the course
PAYMENT:
A ( ) by
Postal Mail: I have accompanied this application with
( ) a check
or money order made out to Project NatureConnect
( ) credit card information (below)
and to sent by postal mail to: PNC Balance Course P. O. Box 1605, Friday Harbor, WA 98250
B. ( ) by
Email Please
charge my credit card $_______________
Type of Card
( ) Visa,,,,
( ) MasterCard
Name on Card:___________________________________
First twelve numbers on Card
______ ________
______ XXXX (do not send last 4 digits in this email)
Call
1-360-378-6313
to report the last four digits or the whole number.
Date of Expiration
MM/YY (Month/Year) ___/___
Personal identification
number on the reverse side of card:_______
Your Postal Address:
City, State, Zip:
C. By FAX ( ) send
B information above with the complete Card number to
360-378-8325