Advanced Registration:
REGISTRATION
BodyTalk
Seminar Registration
Name ___________________________________________________________________________
Address ____________________________________________________________________________
Telephone Home ___________________ Work ________________ Cell _________________
Email _______________________
ADVANCED REGISTRATION
Name of Seminar _____________________________________
Date of Seminar Requested _________________________________
____ Check payable to Center For Mind Body Therapy _______________________________
____ Credit Cards: Charge my credit card - Master/Visa – as follows: _______________
Card Number _____________________ Exp. Date ___________
____Partial Payment Credit Card Option, $330 Registration, $300 at workshop, $300
one month later ($30 Administrative fee)
Authorization signature ________________________________
REGISTER EARLY, LIMITED SEATING Copy form and mail to:
Dr. Jeanette Bevilacqua
Center For MindBodyTherapy, Suite 230,
Fort Myers, Florida, 33919, or register on
www.Bodytalksystem.com
Email bodytalkbevilacqua@comcast.net