First Name:__________________ Midle Name:__________________
Last Names:____________________________________
Date of Birth :___________________________________
Address :______________________________________
City ___________________/ Province__________________ / Postal Code________________
Home Phone number:_______________

Work Phone Number_______________

Cell Phone number________________

SIN Number:________________________

E-mail Address:__________________________________
Are you a Canadian citizen? YES/  NO
Have you got a work visa? YES / NO
Have you got a student visa? YES / NO
If you are not Permanent resident or Canadian citizen, what is your citizens card number and driver’s license number?
Citizens Card Number:______________________________
Driver License Number:_____________________________



High School name and Location:__________________________________________

Did you graduate? YES / NO

Diploma College/University Location/Other Institutes___________________________________________________
Did you graduate? YES / NO


Current or Last Job Title ______________________________________________________________________
Location: __________________________________________________________________________________


Please write the specialization or program you want to take:____________________________________________



I certify that my answers are true and complete to the best of my knowledge and I agree with the following conditions.


1. I hereby sign this form of my free will and completely release Tania MediSPA Ltd from any responsibility, obligation, action, cause of action or  claim for damages arising as a result of any services provided.
2. I understand and agree that any fees pre-paid by myself for services offered by Tania MediSPA Ltd is non-refundable I whole or in part.
3. I understand that any notice for cancellation of the course or program should be given by me to Tania MediSPA Ltd not later than one day after the tuition it has been paid. Only 30% of the money from the tuition fee will be refundable if we don’t receive 24 hours notice. Books are not refundable. Registration fee is not refundable.
4. The full tuition must be paid in full the before the course or program starts.
5. The registration must be paid on the same day that you give your registration form to the school for us to be able to hold your space in the course or program.

Printed name and last name:_________________________________________________________



(Print the registration form fill it out, sign it and scan it back to us by e-mail to





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