Registration Form for Events/workshops/Gatherings at

Mindworks Center for the Self
(This form can be photocopied for multiple registrants)

Please mail this completed form, with your payment, to
Mindworks Center for the Self
c/o Phyllis-Terri Gold
10 Stirrup Lane
Fort Salonga, New York 11768

Credit card payments can also be faxed to 631-269-5330 (Please phone first) or by simply clicking "Community/Contact Us" on the navigation bar on the home page of our web site (www.ptgold.com) and following the simple instructions there.

We are also happy to answer any of your questions about our programs.

Name____________________________________________

 
Street_____________________________________________


City______________________________

Zip code____________

Phone numbers  Day_______________  Evening_______________

Name of workshop(s)/gathering(s)/event(s) for which I'm registering.
 
_______________________________________________________

_______________________________________________________

Total Fee: _______

I am paying by Credit card____ (MasterCard, Visa, Discover accepted)
Underline card you are using.

Name as it appears on my credit card__________________________
My credit card #__________________________ Exp. Date________

I am enclosing my Check/MO_____

Thank you!