CRMA / PSS
Registration Form
  Healing Spirit
        ​Healthcare, LLC
Mailing Address
If you would like to enroll for a class please fill out and submit the form below. Please keep in mind that you are not guaranteed a seat in class unless or until you have submitted payment for that class. To pay using PayPal please go to the corresponding page of the class you would like to enroll in. Thank you for your interest in our services!
Which class are you registering for?
About You
Citizenship
If "No" - what country?
Are you a Maine resident?
If "No" - what state?
Are you a U.S. Citizen?
Payment Information
Will you be sponsored by an agency or provider?
​If "no" how will you be paying for this course?
Who is your contact person within that agency?
What is their phone number and/or email?
If "yes" please tell us who will be sponsoring you:
I hereby apply for enrollment in the above named course.  If I am accepted, I agree to comply with the rules and regulations.  I understand that the information on this form is CONFIDENTIAL and will only be used to determine my eligibility for the program I have selected.  I also understand that any misrepresentation of information on this application and in any subsequent interviews with the Instructor may constitute adequate reason for disqualification of my application and enrollment as a student in the above named course.
Do you have any questions or information you would like us to know?

If you are paying by Check or Money Order, please make payable to:

​Ila Mae
(Course Instructor) 
If you would rather download and print the application instead, please click the button below.
Download now

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