eMail: john@healingtheinsidechild.com
Post: NIRW, 1422 Allendale, Saginaw, MI 48638
Subject: Please Register me for a NIRW Workshop

WORKSHOP LOCATION:

WORKSHOP DATE:

REGISTRANT NAME 1:

EMAIL ADDRESS:

REGISTRANT NAME 2:

EMAIL ADDRESS:

REGISTRANT NAME 3:

EMAIL ADDRESS:

REGISTRANT NAME 4:

EMAIL ADDRESS:

ADDITIONAL REGISTRANT(S):

AGENCY/SCHOOL/FACILITY:

ADDRESS:

CITY:

STATE:

ZIP:

PHONE:

METHOD OF PAYMENT

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AMOUNT $: 

[]Check In The Mail - payable to: National Institute For Resiliency And Wellness

CREDIT CARD: []Visa []Master card

CREDIT CARD NUMBER: 

CVV CODE:

EXP DATE:

NAME ON CARD:

[]I authorize NIRW to charge my credit card for the amount above:

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MESSAGE: