Name *
Street Address or P. O. Box *
(Apartment Number)
City *
State *
Zip *
Country *
E-mail Address*
Web Site URL (if any)
Telephone # (+area code, country code)
DOB *
Profession *

In order for you to participate in homestudy or online courses, Mary will need more than one means of verifying your identity. Please provide and remember the following:

License Number
Special Animal *
Favorite Color *

What is your previous experience with meditation or body work? Describe below.

Do you have a physical or psychological health problem? If so, please explain below:

Are you taking any medications?:

Pay your $75 course fee via PayPal or mail check on US bank Mailing Address: Citta 101, PO Box 20161, Houston 77025 PayPal: mary@citta101.org I understand that meditation teachers are not therapists. I will be open to the process and trust my own heart to know what is true. I will do the work required of the course to the best of my ability, setting aside a total of at least twenty minutes every day for meditation practice.