Workshop Enrollment Form


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Workshop Enrollment Form
To enroll in one or more of Keith's workshops, please fill in the information below.
Please note that information with a red asterisk (*) is required.

Select the workshop(s) you are enrolling for. Check one or more.	"Coaching "U" with Dr. Keith Ward" Monday July 19th, 7 - 9 PM "Coaching "U" with Dr. Keith Ward" Monday July 26th, 7 - 9 PM One workshop: Pre-enrolled and paid online or pre-paid at the Nook: $15.00 Paid at the door: $18.00 Both July workshops Pre-enrolled and paid online or pre-paid at the Nook: $28.00
*Payment Method: Select One (Required)	Prepay Online (Use your credit card or PayPal) Prepay at the Nook Pay at the Door If you are prepaying online, please click on the "Pay Now" button that will appear after you submit this form.
First Name :	*
Last Name:	*
Email:	*
Address 1:	*
Address 2:
City:	*
State:	*
Zip Code :	*
Phone :	*
Birthday:
Please review your form to ensure that one or more workshops have been selected and that all required blocks are filled in before submitting.