Getting In Touch With Yourself & Others Through Massage General Question Title * 1. Contact info Name (First Last) City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Email Address (name@whatEVer.com) Phone Number (XXX) XXX-XXXX Question Title * 2. can I leave messages voice message (discreet, of course) yes no God forbid, "NO" voice message (discreet, of course) messages menu text message (discreet, of course) yes no God forbid, "NO" text message (discreet, of course) messages menu Other (please specify) Question Title * 3. City in which you are wishing to attend the weekend workshop "Getting In Touch With Yourself & Others Through Massage" Question Title * 4. Date(s) you are interested in attending Jan. 2017 Feb. 2017 Mar. 2017 Apr. 2017 May 2017 June 2017 July 2017 Aug. 2017 Sept. 2017 Oct. 2017 Nov. 2017 Dec. 2017 Other (please specify) Question Title * 5. Have you previously attended the weekend workshop "Getting In Touch With Yourself & Others Through Massage?" Yes No If yes, where and when? Question Title * 6. Are you planning to attend the weekend workshop "Getting In Touch With Yourself & Others Through Massage" with someone else? yes no not sure at this time If yes, please provide their first and last name here Question Title * 7. Will you be in need of lodging suggestions while attending the weekend workshop "Getting In Touch With Yourself & Others Through Massage?" yes no not sure at this time if yes, will you have access to transportation? Question Title * 8. Scholarship request - I wish to be considered for the following: Reduced workshop fee Free workshop attendance Each year, I am granted with a fund from a student / client benefactor to help those with special financial needs who wish to attend my workshops and who might otherwise be unable due to financial constraints. If you would like to be considered for this benefit, please use the space below to describe your particular situation. Question Title * 9. Do you wish to secure your attendance in the workshop by: a $ 50 deposit - balance of $ 200 due at the start of the workshop Paid-In-Full (1 person) $ 200 (a savings of $ 50) Paid-in-Full (2 people) $ 350 (a savings of $ 150) Other (please specify) Question Title * 10. Are you interested in possibly scheduling a private session during my / our time in your area? Yes No Maybe commentsOther (please specify) Question Title * 11. Do you have any other comments, questions, or concerns? Next