The Art of Aging
Registration Form

Date (MM/DD/YY):
Name: Age:
Address:
City: Zip:
Email Address:

Preferred contact number for you: Home Work Cell

Emergency contact: Phone:
Emergency contact relationship:

How did you hear about this program?


Briefly describe why you would like to participate in this program at this time:


Describe any special needs (hearing impairment, physical limitations) you have and any special accommodation you need:


Cancellations: Cancel 3 weeks before workshop for full refund, cancel 2 weeks before workshop for half refund. No refunds after that unless we fill your spot.

Please initial here to indicate agreement with the cancellation policy:

Click this button to submit registration form. Pay online using PayPal buttons below.


Ukiah Workshop
San Francisco Workshop 8/9/15

To request reduced fee option, or to pay by check, call Margo at 707-462-1877.