Mindful Living Program Registration Form | Awarenesss and Relaxation Training | Mindfulness-Based Stress Reduction Programs (MBSR)

Registration Form ~ Mindful Living Programs

Print out the following form, complete, and mail with payment to:
Mindful Living Programs ~ 6 Governors Lane, Ste A ~ Chico CA 95926
For assistance, call 831/469–3338 or 530/898-1495.

_____________________________________________________
name

_____________________________________________________
street address

____________________________________________________
city, state, zip

_____________________________________________________
home phone

_____________________________________________________
work phone

____________________________________________________
email address

____________________________________________________
profession: MD, RN, LVN, Psychologist, MFT, LCSW

____________________________________________________
professional license number and date of expiration

I am registering for the following Mindful Living Program retreat:

____________________________________________________
location of retreat

____________________________________________________
dates of retreat

Payment:
___ I have enclosed $300.00 as a deposit
___ I have enclosed $695.00 full payment, paid one month in advance.
___ I have enclosed $795.00 full payment paid after one-month deadline.
___ I have enclosed the discounted $645.00 rate for...

___ Alumni of Mindful Living Retreats
___ Couples
___ Those willing to share a room with one person
___ Massage room (a single room with futon)

Payment accepted as check or MasterCard/VISA.
• Make checks payable to Mindful Living Programs.

MasterCard/VISA #________________________________
Exp date ___________

Signature ____________________________________________