Hosted by Sue Ingalsbe, LCSW-C

Registration Form
Complete this form, print and return with payment

Name:     Phone:     Email:

Street Address:     City:     State:     Zip:

Date of Workshop:     Registration Fee:     Certificate of Attendance:

Age:     Sex:     Race:     Religion:     Marital Status:

Highest Level of Education:     Occupation:    Employer:

Job Title:     Personal Burnout Assessment: (1=trace symptoms; 10=severe burnout)

Hobbies/Interests:

Reasons/Goals for attending this workshop:

Medical/Special Needs/Dietary Restrictions:

Additional Information that may be pertinent to your workshop experience:

Make checks payable to Sue Ingalsbe, LCSW-C
Mail registration form and payment to:
Sue Ingalsbe, LCSW-C
3149 Spring Drive
Westminster, MD 21157

Cancellation Policy: No Refund/Credit given toward future retreat upon cancellation.

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