Inner Focus Events Registration
 Date:_____________

Please print clearly and fill in all the information that applies to you.

Name________________________________

Ph(____)____________________

 Student#______  Fax#(______)_______________________


Address____________________________City__________________ST______Zip______

Email_______________________________________




EVENT REGISTRATION:

  Module      Healing Intensive      Basic/Other_____________________

Location______________________    Date___________

Method of Payment:   Check     Money Order     Credit Card (Please call in #.)

I am enclosing $____________   (Balance Still Due $____________ )

Today's Date_________________

Credit Cards please call in # 
   Checks or Money Orders payable to: Inner Focus