FAX OR MAIL IN REGISTRATION FORM
MindBody Connection Classes or Workshops

Please use one form per person.

Name

Street Address

City

State Zip

Contact Phone

Email

Course/Workshop 1

Dates

Course/Workshop 2

Dates

Payment:

Fees: $

Enclosed is a check/Money Order (payable to Mind-Body Connection)

(with credit card purchase 3.5% added to fee)

Charge to my Visa

Credit Card #
3-Digit # on back of credit card

Charge to my MasterCard

Cardholder's Name

Expiration Date

(Month/Year)

______________________________________________

Please print this form (use Print button).

Fax completed form to: (510) 588-0408
Mail to: Mind-Body Connection; 5855 Doyle St; Emeryville, CA 94608

FOR MORE INFORMATION
CALL TOLL-FREE 1.877.793.6196 or 510.420.0444

angi@mindbodyconnection.net
www.mindbodyconnection.net

2003 © Angi Spector and MindBody Connection  in Emeryville