Your name: _______________________________________________________ Degrees: _____________________
Address: _________________________________________________________
__________________________________________________________________
__________________________________________________________________ Postal code: _____________________
Telephones: cell_________________________; home: _________________________ wk: ______________________
Email address: _______________________________________________________________________________________
Website? : ______________________________________________________________________
I am enrolling in the workshop dates: ________________________ to ______________________________
held in _____________________________________________________________.
I have the following dietary requests: __________________________________________________________________
______________________________________________________________________________________________________
I am especially attracted to the workshop for the following reasons and training requests:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
I have enclosed the minimum registration fee of one-half the workshop fee made payable to Ann E. Hale or Donna Little, to be mailed to Ann Hale, 353 Highland Ave, No. 2, Roanoke, VA 24016
Telephone inquiries: Ann Hale (540) 400-8182 Donna Little, (416) 229-2976
Additional comments and requests:
