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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 $125.00 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. We cannot hold space in the workshop until payment is received.
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