Silva Method Registration Page - William Low

Thank you for signing up for the Silva Life System Program

IMPORTANT: Registration form

Kindly complete the form below, the particulars given will be use to create your membership with Silva International. Upon completion of the program – you will be awarded with a certificate of completion with the particulars below.

Name

Mobile Number

Date of Birth

National Registration Idenfitication Number (NRIC)

Do you need vegetarian meal during the seminar? (only applicable for physical class)

Occupation

Gender

Marital Status

Nationality

Street Address 1

Street Address 2

City

Postcode / ZIP Code

State

Country

Have you been treated of the following; Mental Disorder, Epilepsy or Faint Spells

If answer yes for the above, please elaborate your conditions

Please read, understand and check the box below.

I, the undersigned, hereby pledge to use my knowledge of Silva Method in strict accordance with the laws of Malaysia & United States of the America. Especially I will not use the Silva Method for therapeutic purpose unless I am a licensed physician or psychologist and strictly within the supervising practitioner's areas of competence. Further, I. agree to save Silva International, Inc and /or their authorised representatives, harmless from any liability for any intentional or unintentional misuse of The Silva Method on myself and on others by me. We value our relationship with you and would not sell or disclose your personal information to a third party. We would like to communicate with you on our seminars, notices of events and products which we think may interest you from time to time. Please inform us otherwise. I have read the above carefully and understand it thoroughly.