Community Workshop Registration Form
Please complete the registration form below.
Name
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Email
Your answer
Phone Number
Your answer
Which workshop are you registering for?
Required
How did you hear about this workshop?
How would you like to pay?
*Please note: If paying by check please print off and submit a copy of your registration form with your check.
If paying by credit card, please note charge total
Your answer
Credit Card Number
Your answer
Credit Card Expiration Date (mm/yy)
Your answer
CCV
Your answer
Billing Zipcode
Your answer
Notes/Comments
Your answer
If you have any questions, please contact Jennifer Rolnick at Jennifer@watchhilltherapy.com or 312-498-9715
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