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, Laini Risto, Christina Ensminger, or The Foundation for Shamanic Studies legally responsible for any injury, illness, accident or other misfortune that may occur in connection with my participation in the Way of the Shaman workshop in Las Vegas, Nevada on March 5 & 6, 2011.
Signature____________________________________________________________
Printed Name_________________________________________________________
(PLEASE SEND VIA US MAIL. DO NOT EMAIL)
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. 483, Ashland, OR 97520
Thank
you for your registration. We look forward to
sharing the Way of the Shaman with
you. |