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Registration Form

Print out this form and list the course(s) you are registering for and fax the information to 781-674-3156. You may also mail this form with a check to The Kinesiology Connection or email your registration information to kinesconn@aol.com. A nonrefundable $100 deposit is required for all courses with the exception of the Brain Gym® Introductions.

Send registration via US post to:
The Kinesiology Connection
594 Marrett Road #20
Lexington, MA 02421-7605

For more information call: 781-674-0044

Course(s)
Fee:

Early fee:
(6 weeks
in advance)
Repeat Fee:

Amount
Enclosed:

1.

        
2.        
3.        
4.        
     
Totals:
  

Please place me on your:

_____mailing list

_____email list (let me know if you want to change to our email list, also)

_____I am already on your mailing or email list

Name____________________________________________________________

Address__________________________________________________________

_________________________________________________Zip_____________

Phone h______________________

Phone w__________________

Fax____________________________email________________________

If paying by credit card (Mastercard or VISA):

Name on Credit Card___________________________________

Signature____________________________________________

Card #______________________________________

Exp. Date___________