EmailMe Form - Copy of Student Workshop Registration

Name
Prefix First Last Suffix
Please make sure this is the way you'd like your name to reflect on your certificate of completion.
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Personal Information
Email *
Phone *
### - ### - ####
Workshop Selection
Please select the workshops you would like to attend. Check all that apply.
Select Workshop *
San Luis Obispo, CA [Mar]
Los Angeles, CA [May]
Cheyenne, WY [Jun]
Las Vegas, NV [Jul]
Portland, OR [Aug]
Colorado Springs, CO [Sep]
Seattle, WA [Oct]
Santa Fe, NM [Nov]
Ontario, CA [Dec]
Referral Information
How did you find out about this workshop?
Referral
Advertisement
Friend or Colleague
MassageCupping.com
Search Engine
Trade Show
FaceBook™
Referral [Cont.]

Other
Method of Payment *
PayPal™
Check/Money Order
NOTE: Registration is complete once all dues are submitted. Checks are allowed 3 calendar days after submission.
Image Verification

Please enter the text from the image:
[Refresh Image] [What's This?]

Other