NAME:
PHONE
NUMBER:
MAILING
ADDRESS: (include city, state and zip code)
EMAIL
ADDRESS:
WHERE DID YOU HEAR ABOUT THIS COURSE?
LIABILITY RELEASE FORM
Date_____________________________
I will not hold Beth Beurkens, John Brennan, The Foundation for Shamanic Studies, or Pioneer Hall legally responsible for any injury, illness, accident or other misfortune that may occur in connection with enrollment in the Way of the Shaman workshop at Pioneer Hall, Ashland, Oregon on September 6 & 7, 2008.
Signature____________________________________________________________
Printed Name_________________________________________________________
CHECK
PAYMENT
Secure
your registration by putting your deposit or full
tuition check (made out to Beth Beurkens) in an
envelope addressed to:
Beth
Beurkens, P.O. 840, Mt. Shasta, CA 96067
CREDIT
CARD PAYMENT
Please fill out the form below with your original signature and full tuition amount. Credit card payments may only be made for the full tuition amount.
PLEASE DO
NOT EMAIL THIS CREDIT CARD FORM. YOUR ORIGINAL
SIGNATURE IS REQUIRED TO CHARGE YOUR CARD. PLEASE
FILL IT OUT, SIGN IT AND PUT IT IN AN ENVELOPE
ADDRESSED TO BETH BEURKENS, PO BOX 840, MT SHASTA,
CA 96067 AND MAIL IT USPS.
Thank
you for your registration. We look forward to
sharing the Way of the Shaman with
you. |