Registration for Organ Repositioning Workshop

Registration for Organ Repositioning Workshop

Name______________________________________________________________

Address____________________________________________________________

City_______________________________ State________ ZIP__________________

PHONE
Home______________________ Work_______________________

[ ] I have enclosed full payment in the amount of $125.00

[ ] I have enclosed a $25 deposit. I will pay the balance of $100 during Saturday morning registration

Print and complete this form, then mail with check or money order to:

Sylvia L. Harden
12118 N.E. 142nd Street
Kirkland, WA 98034-1409