Registration Form

course choice ________________________________________________

course date ________________________________

$ _____________

name____________________________________phone__________________________

address__________________________________birthdate________________________

city, state, zip_______________________________________________________

pertinent medical and dietary info_______________________________________

emergency contact __________________________

emergency phone____________________

How did you hear about Touch the Earth?________________________________

Please print and send this form with $100* non-refundable deposit to:

Touch the Earth - P.O. Box 2136 - Pagosa Springs, CO 81147-2136

* (U.S. funds only; check or money order payable to Touch the Earth)