Alternative& Integrative Medical & Pediatric Specialist: Medical Intuitive, Distant Energy Healing
  PO Box 475    Southern Pines, NC 28388 USA
   NC Phone: 1.910.692.5206 USA         NC Fax: 1.910.692.5103        Atlanta, GA Phone: 1.404.242.9022 USA
   Email: Brent@BrentAtwater.com                    Date: October 06, 2011

                                                                                REGISTRATION FORM

Date of Workshop: _______________ 2006                  Fee for Workshop: $ ____________

Location:_____________________________________________________________________ 

Course(s):_____________________________________________________________________

To reserve your place in Brent Atwater's Workshop, Course or Seminar,
Please fill out these 2 pages completely & email or return to NC Office listed above.
  
 Name:_______________________________________________________________________

 Address:______________________________________________________________________

 Address line 2:_________________________________________________________________

 City:__________________________________________________________________________

 State:_________________________________________________________________________

 Zip Code:_________________________

 Phone: _______________________________  Cell Phone: _____________________________

 E Mail:___________________________________

 Profession:____________________________________________________________________

 Please describe your interest in attending this course, and anything specific you'd like us to know
 about you.
_____________________________________________________________________________________

_____________________________________________________________________________________

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Suggestions for future courses:__________________________________________________________

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                   Alternative& Integrative Medical & Pediatric Specialist: Medical Intuitive,  Distant Energy Healing
                                         PO Box 475    Southern Pines, NC 28388 USA
 NC Phone: 1.910.692.5206 USA         NC Fax: 1.910.692.5103      Atlanta, GA Phone: 1.404.242.9022 USA
                                                         Email: Brent@BrentAtwater.com      
 
                                                   Registration Form page: 2 of  2
  Cancellation Policy

Since there is limited registration for this course there is a $150 processing fee for any cancellations. If
cancellation is in by 10 business days prior to the workshop there is full reimbursement minus processing fee.
If cancellation is after the 10 business days prior to the workshop, there is full reimbursement minus processing
fee if your space is filled by another student. We will put forth best efforts to fill your place with another student,
but if that isn’t possible there will be no reimbursement.
 
 Method of Payment

 If I pay by debit or credit card , I understand that by providing the following information to Ms. Atwater,
and Energy Work, Inc., that I agree to and I legally authorize that the debit or credit card below be charged
to pay for Ms Atwater's Workshops, Courses or Seminars. This authorization may only be terminated by the
individual or legally authorized agent of said person who owns this card, and only by written notification sent
via certified mail to Energy Work, Inc. at the address above.
     If I pay via PayPal, I agree to and authorized that transaction to pay for Ms Atwater's workshops, Courses or Seminars. The PayPal  email address is Brent@BrentAtwater.com.                                       

 Personal Check:__________     Money Order:_________   Pay Pal:_____________

 Credit or Debit Card:________   Type of card:_______________________________________

Name as it appears on the card:__________________________________________________   

Card number :___________________________________________________Please Print CLEARLY

Expiration date of card :_______________________

The last three numbers on  signature strip:_____________

The Billing Name and Address as it appears on the card's statements:

_______________________________________________________________________

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Thank you.