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To apply for this intensive, submit the following items along with your completed registration form and payment-in-full. Please submit all items together at the time of application.
We are sorry that incomplete applications cannot be accepted.
New Students: If this is your first intensive with Rosalyn and Ken, please provide the following additional typed information with your registration, limiting your answers to 1-2 paragraphs per question.
Name_______________________________________________
Address_____________________________________________
City________________________________________________
State/Prov_____________Zip____________________________
Home Phone__________________________________________
Work phone__________________________________________
Email_______________________________________________
Name for ID Tag______________________________________
Emergency Contact Name__________________________________
Emergency Contact Phone#__________________________________
$1075 Regular Fee Commuters add $125
Check # ______ payable to Liz Chazen and/or
MC Visa Disc AMEX CC#____________________________________ Security Code (3 digit code on back):______ Ex. Date:__________
Dietary Preference: We cannot accommodate special diets. But Liz will do her best to have the following available for you. Please circle your preference. All foods Gluten-Free Vegetarian
Room Share: Would you like to share a room? Yes No If yes, please give your gender and age. Male Female Age: _________
To register for this workshop please fill out the form above and mail it along with your payment, AND color photo to the following address.
Liz Chazen 18 Cambridge Lane Lincolnshire, Illinois 60069
OR,
Email Lizchazen@gmail.com to register with email, please copy and past this registration filled out completely.
Questions? Please feel free to phone Liz Chazen at (847) 767-3663.