HOST A WORKSHOP REGISTRATION FORM
Dear Workshop Host,
Thank you for your interest in hosting a Seeds for Change Wellness workshop!
Please print out the following form, then complete the required information:
Workshop You Plan to Host: ________________________________________
Dates of Workshop: ________________________________________
Address of Workshop Location:
_______________________________________________________________
_______________________________________________________________
Minimum Number of Participants Required: ____________
Name of Host: ____________________________________________
Address:
_________________________________________________________
City:_____________________________ State ____________________ Zip:_______________
Home Phone: ____________________________
Work Phone: ____________________________
Cell Phone: ____________________________
Email: ______________________________________________________
Enclosed is the required $25 non-refundable deposit.
I understand this deposit commits Seeds for Change Wellness to facilitate the contacted workshop on the designated
date(s) and times of the event specified above.
I agree as the program host to forward all fees associated with this workshop one week prior to the scheduled class,
which is due on __________________________.
I understand failure to submit the required registration fees on the designated date will result in the event being
cancelled and my deposit is forfeited.
Host Signature: ______________________________________ Date: _______________________________
PLEASE RETURN THIS FORM TO:
Seeds for Change Wellness Make Deposit Check Payable to:
105 Oak Drive Seeds for Change Wellness
Sellersville, PA 18960