Reflexology Science Institute    98-09-1496T
1170 Old Henderson Road, ste 206
Columbus OH 43220

 Registration Form for workshops and classes.
For Reflexology Certification use enrollment form.  Use this form for all other classes
Print this form to complete.

Class Title:____________________________________________Date(s):_________________

Class Title:____________________________________________Date(s):_________________

Class Title:____________________________________________Date(s):_________________

Name:_______________________________________________Phone:__________________

Address:____________________________________________________________________

City:_________________________________________ State:_______ Zip:_______________

( ) Mastercard ( ) Visa ( ) Discover ( ) Amex    Card Number:____________________________

Signature:_____________________________________________ Exp Date:_______________

Registration fee is $50 for each class.  You may register by calling our office at
(614) 457-5783 or by mailing this form with check, money order or credit card information.   Registration is required for all classes.