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Jill Fein Baker, LCSW
5225 Old Orchard Road, Suite 3    |    Skokie, IL  60077    |    847-470-1618

Getting the Love You Want Workshop for Couples
 Mail Registration Form  
1. Fill in the form below.
2. Print out completed form.
3. Mail along with payment (check, money order, or credit card info) to the address above.
Name:
Address:
City:

State:

Zip:
Email:
Phone: (day) (eve.)

Partner's Information:

Name:
Address:
City:

State:

Zip:
Email:
Phone: (day) (eve.)

Workshop Date:

Date:

Payment Information:

Amount:
Other Amount:
 $ For:

Check (payable to Jill Fein Baker)

Money Order
VISA:

MASTERCARD:

AMERICAN EXPRESS:
Card #:
Exp. Date:
Please choose a referral source:
if other:

Cancellations:  If you cancel eight days or more prior to the workshop you will receive a full refund minus a $100.00 administration fee. If you cancel seven days or less prior to the workshop, you may transfer your registration fees to another scheduled workshop, however, no refunds will be made. If the workshop is cancelled by the presenter, a full refund will be made.