Registration form for Continuing Education Events                                 
Print, complete, and return along with your payment to:
Mind Body Connection.

Class Title: _______________________________________

Class Date:_______________________________________

Your Name: ______________________________________

Address: ________________________________________

 _______________________________________________

 _______________________________________________

Phone: (       )     __________________________________

Email: __________________________________________

(  ) I have enclosed payment in full of: $_________

(  ) I have enclosed a deposit of: $_________

Visa or MC (circle one): #___________________________

Name on card: ___________________________________

Expiration Date:__________________________________

Signature: ______________________________________

Please make checks payable to:

         Mind Body Connection

Mail to:

         2416 Music Valley Dr, Suite 119

         Nashville, TN  37214