Canada's National Association

Committed to developing highly trained reflexologists since 1978.

On-Line Membership Renewal Form

Please be sure to complete ALL sections of the form. Once the form is complete, click the Submit button at the bottom of the form. PLEASE NOTE: Your application will not be processed until payment is received. Required fields are denoted by *

    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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