Life-Steps Registration Form

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Life-Steps Registration Form

Yes, I am interested in participating in the Life-Steps course. Enclosed is my payment for $375.00. _______

or

Yes, I will take the refresher five courses
at $125.00 ______

Name: ___________________________________________

Address: _________________________________________

City/Stat/Zip: _____________________________________

Phone: __________________________________________

Cellular Phone: ___________________________________

Fax: ____________________________________________

E-mail: __________________________________________

Please mail the completed form, along with your payment to:

Chiro-Med Rehabilitation

8660 E. Shea Blvd, Suite 9

Scottsdale, AZ 85260