HYPNOVATIONS

REGISTRATION - Intermediate____

October 19 - 21, 2018

NAME ______________________________________________

ADDRESS _________________________________________

__________________________________________________

CELL ________________________WORK ___________________

EMAIL______________________________________________

PROFESSION _____________________ SPECIALTY _____________

_________

LICENSE # ___________________TERMINAL DEGREE ___

(Students Only)

GRADUATE SCHOOL ________________________________

DEGREE __________ ANTICIPATED GRADUATION DATE______

REFERRED BY: ____________________________________________________________

Where & when did you complete your ASCH approved Basic workshop?

_____________________________________________________

Hand-outs available to download for free via 

1 week prior to the workshop

or pre-order printed hard copy for an additional $30

Registration Fee:  $500

NMSCH members $475

Dental/Medical/Mental Health Graduate Student: $450

Printed Hand-outs:

$30

Total _________

Make check payable to:

Hypnovations

OR

Credit card: _____M/C _____Visa

CREDIT CARD # _________________________________

EXPIRATION___________      SECURITY CODE_________

CARD HOLDER’S NAME & ADDRESS_______________________

______________________________________________________ ______________________________________________________

SIGNATURE _______________________________________

Fax to 802-419- 3829 or mail to:

Maureen Turner, Co-Director

HYPNOVATIONS c/o Motivation Hypnosis

31 Main Street, Suite 6, Burlington, VT 05401

ADDITIONAL INFORMATION: Maureen Turner at 802-338-8040

REFUNDS: A $30 handling fee is deducted for cancellation.

Refund requests must be received one week prior to the course or no refund available.

LOCATION 

Jackson Gore Inn at Okemo,  Ludlow VT

LODGING - available at Jackson Gore or see Ludlow Lodging tab