Registration Form for

The Virtual Gastric Band

6-Week Online GROUP COACHING PROGRAM

scheduled to begin on Tuesday, July 17, 2018

Please tell me who REFERRED you (so I can thank them)... or how did you learned about this workshop (so I know how to spend my advertising dollars in the future)?

Your Name:

First Name

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Your Email Address:

Your Address:

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Email List

May I add you to my email list for my interesting E-zine & email promotions for my healing workshops, energizing groups, and personalized private sessions? Your email address is always kept confidential. Email promotions are usually monthly.

No thanks

YES! PLEASE!

GROUP Course Registration Fees

$ 175 for the "Virtual Gastric Band Hypnosis Program" - GROUP Course of 6 Weekly Classes beginning on Tuesday, January 9, 2018.

Subtotal for GROUP Course:

$

GROUP Course Discounts:

$ 50 Discount for Early Registration - This form must be received with fees due by 11 pm on Tuesday, January 2, 2018 (7 days before the Workshop start date).

$25 Discount if you are registering with ONE friend. (Type the name of your friend in space provided towards bottom of form.)

Total Amount to be Paid

[Subtotal for GROUP Course(s) or Workshop(s) less ( - ) Subtotal for All Discounts Applicable]

$

Today's Date

MM

DD

YYYY

I authorize Linda Greenfield to charge the following amount to my credit card information:

$

Type Name of Credit Card Holder:

Zip Code of Card Holder:

Credit Card I am using:

MasterCard

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Credit Card #:

Credit Card CVV Code:

Credit Card ExpirationDate

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Enjoy attending with a FRIEND & receive a discount!

When you register with a FRIEND, each of you will receive $25 off! When you register, just list the name of the friend that is also registering and attending this same program / course in the following space provided:

Do you have any Questions or Comments? Type coupon codes here.

REFUND POLICY:

Refunds for any pre-registered Courses or Workshops (less $25 for processing fees) provided only by cancellation request received in writing (email or letter) at least one week prior the scheduled start date of Course or Workshop.

Other information:

Linda personally processes all credit card payments through Point of Sale (Previously Square). Point of Sale will e-mail to you a receipt for your payment. You will also receive a printed receipt directly from Linda for your payment at the first class.

If you need to contact Linda Greenfield for any reason, please call 305-519-9711 and plan to leave a voice message.