Registration: Fax to 304 414-3633, email to IntegratedHealingServices@msn.com

Or mail to Integrated Healing Services PO Box 8876 Charleston, WV 25303

Questions ? (304) 414-3629 or 304 726-7681

{Minimum 6, maximum 12} One participant per form 

Name:       ___________________________________________________________

Address:    ___________________________________________________________

                    ___________________________________________________________      

Phone: H: ________________________ C:____________________

Email:         ______________________________________________

CC#           _________________________________________  Exp ________ Code______

 

Occupation: _____________________________________________

 

Are you attending with a significant other?  Yes_____   No_____

Their name (if yes):______________________________________________

Fees must be paid with registration to reserve space

 

Please rate the following options in order of preference; X if not desired:

(Subject to availability; will be scheduled by workshop hosts on a 1^st come 1^st serve basis)

                      Reiki        _________                                        Massage ______

Lavender Bath_________ Private Outdoor tub, attendant (State if couple wishes to bathe together)