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REGISTRATION FORM 

Name____________________________________________________________________________

Email or fax # (for confirmation purposes)__________________________________________

Daytime phone_____________________________________________________________________

Address__________________________________________________________________________

City/State/Zip______________________________________________________________________

For credit card payments, please complete the following information. Credit card payments may be faxed.

Credit card type (circle one):        Visa     Mastercard     American Express     Discover

Exp. Date _________________

Name as it appears on the card if different from above _________________________________

Billing Address (if different from above)_____________________________________________

Card Number _____________________________________________________________________

Authorized Signature __________________________________________

Workshop dates are subject to change or cancellation.  Deposits made for a date that is cancelled will be refunded or may be transferred to another workshop date.  Participant cancellations must be received two weeks prior to the event.  Cancellations received within two weeks of the event are not refundable but can be transferred to another workshop date.  Cash or credit cards for full tuition are accepted the day of the seminar. Discounted early registration fees, when available, must be paid in advance by credit card confirmation via telephone or by sending check or money order postmarked one week prior to event.  Make checks payable to NHK and send to:

Nurtured Heart Kids, PLLC

16D Uvalde Rd., #236, Houston, TX 77015

fax # (713) 637-6009 / phone registration (281) 728-7181