Workshop Registration Form
   
First Name
Last Name
Address
City
State
Zip Code
Country
Daytime Telephone
123-456-7890
Evening Telephone
123-456-7890
E-mail Address
name@domain.com
Female    Male
Name of Gender Balance
if applicable
Desired workshop Location, Level and Dates
Reg-Code (optional)
Meal preference
Transportation

We will contact you during our business
hours, East Coast time, 9:00 a.m. to 5:00 p.m.
At which of the above phone numbers are we
more likely to reach you during our business hours?

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Human Awareness Institute Midwest
856 Ardmore St.
Dearborn Heights MI 48127-4111
313-791-8566
Contact By Email

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