Workshop Registration

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WORKSHOP REGISTRATION
Return this form to:
Innovative Therapy Services
1090 Homestead Road, Santa Clara, CA 95050
EMAIL:
or
FAX: (408) 241-3156
th
DATES: January 16
, 2015
TIME: 9:00 am to 4:00pm
LOCATION: 1090 Homestead Road,
Santa Clara, Ca 95050
There are limited spots for this class to ensure optimal hands on learning. Please enroll early
COST: $60 Registration can be by mail, phone or fax. If mailing, please address in stamped envelope.
Do not email your credit card information. If emailing registration, call and give your credit card
information.
(Registration two weeks before event date, $65.00)
If you need accommodations please call at least two weeks prior to the event date and we will be
happy to assist you.
NAME : _____________________________________________
ADDRESS:_____________________________________________
EMAIL:________________________________________________
PHONE:____________________________
DATE:_________________________
Cardholder name: _____________________________________
Card #: ______________________________________________
Exp. Date: _______________________________________ 3 digit CVC:_________
Signature:_____________________________________________

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