CROSSROADS CHRISTIAN COUNSELING
CROSSROADS LIFE AND PARENTING COACHING
PROFESSIONAL COUNSELING AND COACHING
CHRISTIAN VALUES
SIGN UP HERE - Print and fax or email this form to Demi - see below
Name 1____________________________________Name 2 ___________________________
Payment in full due by Nov 1. Please indicate amount you are sending or charging now.
Circle one - $25 deposit - or $167 early bird - or $195 regular fee - times #of attendees _____ = $________
Email address ______________________________________________****needed to acknowledge your payment
Street address_______________________________City___________Zip___________
Home phone_________________ Cell Phone ____________________ Need ins receipt? Y N circle
Payment method: ____Check ____Cash _____Credit Card _____Debit Card
Name on Card__________________________________________ Visa MC Discover Amex (circle one)
Card Number - ______________________________________ Exp Date________ Code _______
Mail, fax or email. Checks payable to Demi Wood, mail to 1218 Hawkeye Ct Fort Collins CO 80525.
For credit cards - Confidential fax line 206-350-3364. Or email this info to demianwood@yahoo.com.