Canada's National Association

Committed to developing highly trained reflexologists
since 1976

Membership Renewal Form

2005 Renewal Form.doc

2005 Membership Fees

    Donations are accepted with thanks.
    If you would like to make a donation, please add it to your membership fee.

  1. Canadian residents:

    $107 (except Nova Scotia, New Brunswick, Newfoundland and Labrador) � includes GST
    $115 (only Nova Scotia, New Brunswick, Newfoundland and Labrador) � includes HST

  2. Non-Canadian residents:

    $100 only (taxes not applicable outside Canada)

    Membership Fees UNCHANGED for 2006

    Just to let you know... Membership fees are UNCHANGED for 2006!

Section 1 - Mailing Address
Application Type* Renewal
Member Type* Certified
Member No
Certificate No
Preferred Language* English French
First Name*
Last Name*
Postal Code*
Business Name
Home Phone*
Work Phone
Cell Phone
Work Fax
Section 2 - Referral List Information
Note: The following information is that which you want the public to have. The ability to be registered is only offered to RAC certified reflexologists in good standing.

I confirm that I am RAC certified and I wish to have my name given out as a referral:

Please complete all fields in this section:

Allow Referrals* I Agree I Disagree
Nearest Intersection
Referral City
Referral Province
Referral Fields Work Phone
Home Phone
Cell Phone
House Calls Yes No
Section 3 - Demographic Information
Note: The following information will only be used by the office for gathering data for medical/dental and other group insurance discount programs.
Age Group 18-25 26-30 31-44
45-54 55-64 65+
Gender Female Male
Marital Status Single Married
Children Under 25
Formal Education High School
Some Post Secondary
College Diploma
University Degree
Post Graduate
Practice Frequency < 20hrs 21-30hrs
30hrs+ per week
Treatment Charge < $30 $30-$50
$51+ per visit
Practice Location
Other Modalities
Which products/services do you wish you could purchase at a group discount?
Group Discounts
Section 4 - Comments & Suggestions
Section 5 - Payment Details
(Payable in Canadian funds only please)
Payment Method* Visa Master Card
Name On Card*
Card Number*
Expiry Date*
Section 6 - Contact Information Release
By submitting the information contained in this form as a Certified member of the Reflexology Association of Canada; I hereby provide my permission for my contact information - including my e-mail address - to be added to the RAC Member and / or Teacher online referral directory. I acknowledge that my contact information will only be displayed on the RAC referral system as long as I am a certified member in good standing. I agree to contact RAC if my e-mail address changes in order to ensure this system is current.
Acceptance I Agree I Disagree


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