Guiding Mindful ChangeTM Registration Form
TO REGISTER: Print this form & fill it out. Include Credit Card # & Exp. FAX or mail completed form to us.
Note for Group Discount:  Please register together, and submit a form for each person.

Name:
Address:
City:                                                         State:                                                        Zip:
Phone:                                                     Email:
Web Address:

Please complete here or attach a separate sheet:

DEGREE (S):                                         LICENSE #:

Relevant Background:

Discuss your current Mindful Practices:

What would prevent you from completing this training?

Physically Challenged?       YES          NO    If Yes, what special accommodations do you require?

Training Dates & City you will attend:

 

 

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

Card #: ____________________________________________

Exp. Date: _________________________________________

Signature of Cardholder:______________________________

Refund Policy: Cancellations must be made in writing postmarked at least seven (14) days prior to the training date for refund less a $250 non-refundable deposit. Refunds are issued within 30 days. If, for any reason, you need to cancel within 7 days or are unable to complete the training, you may qualify to transfer to another training within 12 months of the original training date.

Tuition:  Full tuition for training $3250 A non-refundable deposit of $250 is suggested to reserve your space. (Balance due 10 days prior to first day of training.)

-- SAVE $325 - Early Bird 1:
If paid in full and received at least 6 weeks prior to first day of training.

-- SAVE $175 - Early Bird 2:
If paid in full and received at least 3 weeks prior to first day of training.

-- SAVE $50.00 - Group Discount:
Per person when registering with 3 or more colleagues. May be combined with "Early Bird" registrations.  Please register together and submit a form for each person.
 
-- Please tell us how you heard about this program:

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 - 2008, Guiding Mindful ChangeTM. All rights reserved.