First Name

Last Name

Desired Name on Nametag

Organization

Position

Mailing Address

Address

City & State

Country

Zip Code

E-mail address

Re-enter E-mail address

Phone #

Fax #

Emergency Contact

Name

Phone #

Relationship

Workshop Date

Dietary Needs & Restrictions

Name on card if different from your own:

Cancellation Policy: Cancellations must be made 30 days in advance to receive a full refund. If paying by check, some paperwork is required to receive a full refund. Credit card registration cancellations only require notification.