Registration Form & Mailing Instructions

June 17 – 19, 2011 — Energy Healing For Those Who Care

To apply for this weekend workshop, submit the following items along with your completed registration form and either your deposit or payment-in-full.

Required Supplies:

Please bring a journal or notebook, pen or pencil to take notes with, and colored pencils or pens to draw with.

Registration Form

Name_______________________________________________

Address_____________________________________________

City________________________________________________

State/Prov_____________Zip____________________________

Home Phone__________________________________________

Work phone__________________________________________

Email_______________________________________________

Name for ID Tag______________________________________

Emergency Contact Name__________________________________

Emergency Contact Phone #__________________________________

$345 Registration Fee (You must pre-register to insure space.)
$25 Friday evening only

Check # ______ payable to Kathy miritello and/or

MC Visa Disc AMEX
CC#_________________________________Ex. Date________

Dietary Preference:
Regular (no restrictions)
Vegetarian, including dairy & eggs.
Gluten-free

Please mail this completed form, along with your payment to:

Kathy Miritello, 19 Pacifico Dr., Asheville, NC 28806-8203

Prefer email? Please copy/paste your completed application into an MS Word document and send as an attachment to: k_miritello@bellsouth.net. Remember, email is not secure — Please call me with your credit card numbers in accordance with the dates above.

Questions? Please feel free to phone Kathy at (828) 545-7646.