PRINT AND MAIL-IN REGISTRATION FORM


Workshop Date _____________________

This demonstration workshop is not designed as a substitute for professional consultation or therapy where indicated. It is designed as an education program only. I understand that this workshop may bring up issues of a highly personal nature that may cause me to experience emotional or physical responses that may be unexpected and/or unpleasant. By signing this document below, I willingly agree to hold harmless and release from all liability the organizers, facilitators, and participants in this workshop.

I agree to respect the confidentiality of the participants within the course of this seminar.

I will not discuss anyone's personal process outside the meeting space.

Participant Signature __________________________Date_______

Name of Participant (please print)___________________________

Address:_______________________________________________

Phone:_______________________________

Email:_______________________________

Workshop cost is $100.00 per person, payable and sent to:
          Healing Arts of Belmont
          7 Williston Road
          Belmont, MA 02478

Cancellation: Cancellations made 7 days or more prior to the workshop will entitle registrants to a full refund, minus the administration fee of $20.00. No refunds can be made if cancellation occurs within 7 days or less of workshop date.

________Yes, I would like to be on your mailing list for future workshops

________No, I would not like to be on your mailing list

Please print, sign and mail this form to us with your payment to hold your space in the workshop.