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

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street address

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city, state, zip

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home phone

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work phone

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email address

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

____________________________________________________
professional license number and date of expiration

I am registering for the following Mindful Living Program retreat:

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location of retreat

____________________________________________________
dates of retreat

Payment:
___ I have enclosed $300.00 as a deposit
___ I have enclosed $950.00 full payment, paid one month in advance.
___ I have enclosed $1050.00 full payment paid after one-month deadline.
___  I have enclosed the discounted $850.00 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 ____________________________________________