To Register for

Print This Registration Form and Mail to:

PLEASE PRINT CLEARLY

Today's Date ______________

 Name #1______________________________________________________________________

 Name #2______________________________________________________________________

 Street Address_________________________________________________________________

 City________________________________ State____________      Zip____________________

 Tel: Day__________________ Eve_______________________ Fax______________________

 E-mail________________________________________________________________________

 Specify Workshop Dates_______________________________________

Registration Fee (please check one):

 q One Adult  - Cost = $125.00           q   Two Adults - Cost = $200.00  

  Payment Information: Do Not Send Cash

Enclosed is my check for $_________  (payable to The Connection Clinic)

Or:  I want to pay by credit card:  q   Visa      q Mastercard

Charge my credit card $____________________ Exp. Date________

Account Number________________________________________________________________

Name ________________________________________________________________________  

(exactly as it appears on card)

Signature_____________________________________________________________________

 Contact The Connection Clinic:

Phone    503-238-9755           Email     robp@connectionclinic.com          

How to register:

You may register for The INSIGHT Workshop by phone, by fax, by mail or on-line www.connectionclinic.com.  You will be called shortly receipt of your registration.  You will also receive confirmation by email or letter.  If you don't receive your within 48 hours of your registration please contact us by phone. 

Pick Up your Insight Workbook:

Call The Connection Clinic and we can place a book at Ruby's Coffee Shop at 35 NE 20th (a small friendly coffee shop exactly one door east of The Connection Clinic). 

Cancellation Policy:

If you must cancel prior to three weeks before the workshop date, a full refund minus a $30 processing fee will be given.  For cancellations thereafter, you will be given credit to attend any of The Insight Workshops offered within the next 18 month from date of initial registration. Any workshop you know you will miss may be recorded on audio or video for your

Special Situation Notice: 

If you must miss one of the workshops in a series and give us at least 24 hours - we will arrange for an audio or video recording of the lecture for your personal use. 

Questions?

Please contact us by phone 503-238-9755, or email us at robp@connectionclinic.com