WENDI WHITE, LMT AND NCBTMB CEU EDUCATOR #1325

Continuing Education Registration Form

Please complete and return with payment to:

Wendi White, Graham Family Chiropractic, 1785 Baltimore Pike, Hanover, PA 17331, or email form to: fibrofit2013@gmail.com

Today's Date:                                            License #:                                                       
Name:                                                                                                                               
Street Address:                                                                                                                 
City:                                                 State:                               Zip Code:                          
Phone:                                                   Email:                                                                  
Male:                                        Female:                                      Pregnant:                       
Special Challenges:                                               Allergies:                                              

WORKSHOP INFORMATION: All classes are approved by NCBTMB:
Name of Class:                                                           Date of Class:                                                                                         

Time of Class:                        Cost of Class:                             Class Location: Hanover

PAYMENT INFORMATION: All classes must be paid in full prior to class date:                                                                                                    

Check #:                                            Amount of check:                                                                                                            

Cash:                                                   Amount of cash:                                                                                                            

__ PAYPAL, please check here and I will email you an invoice via PAYPAL

Cancellation Policy We understand that unanticipated events happen occasionally in everyone’s life. In our desire to be effective and fair to all students, the following policies are honored: Student will be refunded 100% if class is canceled by instructor. 100% refund if student withdrawals from class 30 days or more prior to date of class (Fees may apply). Student will not receive a refund if withdrawal is after 30 days of scheduled class. A credit will be kept on account for a future class. Special exceptions may apply. Students are responsible to locate & register for an alternate class on their own. Classes are not guaranteed to take place and could be canceled due to low enrollment, weather, etc. Please check with us before you make travel arrangements.

By completing this form, I understand and agree to the above policy, and the following: The instructor is not responsible for any unintentional harm or loss that may occur to me, or my clients, before, during or after a class. I understand that it is my choice to participate in the "hands-on" instruction, class activities, and promise to use the information and techniques taught to me in a legal, ethical, and professional way. I have read the description of the class(es) I have registered for, and verified the acceptance of the classes by my State Board of Massage Therapy.