Somatic Dialogue Registration Form


Janet Evergreen, MA
115 RiverBluff Circle, Charlottesville, VA 22902
(434) 906-4181

Howie Evergreen

NOTE: If you are taking this class with a partner, you each need to complete this form individually.

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Email *
Name *
Address *
Telephone Number *
Communication Preferences: *
Birth Date and Age *
Familial Status  (i.e. married, partnered, single, divorced, children, grandchildren...) *
Class Agreements *
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