Registration Form & Mailing Instructions

June 8–10, 2012 — Sight and Insight — A View from the Third Eye

To apply for this weekend workshop, submit your completed registration form and your 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__________________________________________

Cell phone__________________________________________

Email_______________________________________________

Name for ID Tag______________________________________

Emergency Contact Name__________________________________

Emergency Contact Phone #__________________________________

$315 Early Bird Fee (due, in full, May 11. Includes Friday Evening Lecture)
$345 Regular 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________ CVV/CID#_____)

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.