Guiding Mindful ChangeTM Registration Form
TO REGISTER: Print this form & fill it out.     FAX or mail completed form to us.

Name:


Address:


City:                                                         State:                                                        Zip:


Phone:                                                     Email:


Web Address:

DEGREE (S):             LICENSE #:
Physically Challenged?       YES          NO    If Yes, what special accommodations do you require?
Advanced Practitioner Techniques Teleclass Workshop
 
Date:

 

 

Form of Payment:   ___ Personal Check
                             
                               ___ MC / Visa / Discover

Card #: ____________________________________________

Exp. Date: ______________________Security Code _______

Signature of Cardholder:______________________________

Refund Policy: Cancellations must be made in writing postmarked at least seven (7) days prior to the training date for refund less a $50 processing fee. Refunds are issued within 30 days.


Tuition:  Full tuition for training is $199.
A deposit of $50 is requested to reserve your space. (Balance of $149 is due 7 days prior to the day of the training.)

 

 

Mail or Fax Registration to:
Guiding Mindful Change
5663 Balboa Avenue, #438 San Diego, CA 92111
FAX:  (858) 571-8764             PHONE:  (619) 297-7542

© 1999 - 2007, Guiding Mindful ChangeTM. All rights reserved.