Registration Form

Benevolent Touch Workshop and

National Instructor Certification Course

Please copy this form and send it in with the registration fee.

I wish to register for the following BT Workshop:

_________________________ at $50 per person.

(Deadline 1 week before each session).

 I wish to register for the following BT National Instructor Certification Course:

__________________________  at $500 per person.

(Deadline 1 week before each session).

Please note: The National Certification Program is only open to those who have attended a standard Benevolent Touch Workshop. You may sign up for both the workshop and National Certification Course using this form.

Name: ____________________________________________________________

Occupation: ________________________________________________________

Company/Organization: _______________________________________________

Address: __________________________________________________________

City: ___________________State/Zip: ____________

Phone: _____________________________________

                 Work                   Home

Total amount enclosed: $________________________               

For more information please call (414) 977-5056

Email: sandya@stanncenter.org

Fax: (414) 977-5011

Please make checks payable to St. Ann Center and send to:

St. Ann Center for Intergenerational Care

Benevolent Touch

2801 East Morgan Avenue

Milwaukee, Wisconsin 53207