and
Mail this Registration Form to Psychological and Life Skills Associates,
P.C.Please Print and
Mail this Registration Form to Psychological and Life Skills Associates,
P.C.
REGISTRATION FORM (copy as needed – one per person)
Address:
Class/Retreat ______________ Date(s)_______________ Fee__________ Class/Retreat ______________ Date(s)_______________ Fee__________ METHOD OF PAYMENT: Amount
$ ___________ (Please
do not send cash in the mail) □ Check Enclosed – Payable to: Psychological and Life Skills Associates □ Credit Card □ Visa □ MasterCard Credit Card Number ___________________________________ Exp. Date: ___________ Name on Card: _______________________________________________ Authorized Signature: __________________________________________ If you cannot attend, please cancel at least 7 days prior for a refund. Late cancellations and “No Shows” are not reimbursed. Mail To: Life Skills Program Phone (703) 490 - 0336 Fax (703) 490 - 4525 E-mail: psychlife@psychlife.net Web: www.psychlife.net |