Brain Injuries Workshop Registration

Name*

Email*

We have been having problems with certain email providers, including Yahoo and AOL. If your primary email is with YAHOO or AOL, please also leave an alternate email below.

Alternate Email

For YAHOO and AOL users

Phone Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I am licensed as a:*

For NCCAOM PDAs

Please provide your State Acupuncture license #, NCCAOM #, and date of birth if you would like NCCAOM PDAs

BIPOC, LGBTQ+, or First-Generation Immigrant?

In the spirit of cultural transformation through healing, if you are BIPOC, LGBTQ, or a first-generation immigrant, please check this box to receive 25% off fees.

BIPOC, LGBTQ+, or first-generation immigrant

I am registering for:

Sun, Feb 2, 2025 at Crossings in MD
Sun, Mar 9, 2025 at True Life Center in CA

I am registering for:

Fees reflect 25% discount

Sun, Feb 2, 2025 at Crossings in MD
Sun, Mar 9, 2025 at True Life Center in CA

Other Payment Amount

Enter other (if any) payment amount here.

Payment Method*

Checks should be made payable to "Integrative Healing, LLC" and mailed to Integrative Healing, LLC, PO Box 204, Hyattsville, MD 20781. Receipt of your fee will hold your space.

Credit Card
Check

Total

$0.00

Credit Card

Card Details

Cardholder Name

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