Registration Form

Name:_________________________________________________________
Address:_______________________________________________________
City:___________________________________________________________
State:_________________________________ Zip:_____________________

Email Adress:___________________________________________________

Home Phone:____________________________________________________
Work Phone:_____________________________________________________
Deposit Enclosed: $_______________________________________________
Method of Payment (please circle one) • check • money order • Visa • Mastercard
Credit Card #__________________________________________
Exp. Date:________________________________________________________
Signature:________________________________________________________
Make checks payable and mail with form to the appropriate center:
The Trinity Center of Dallas - Dallas, TX

Margaret Clench RN, PhD, ThD
Director of The Trinity Center of Dallas, Inc.
3628 Vintage Place
Dallas, TX 75214
Phone: 214-754-8080
Fax: 214-370-973
0
email TrinityDallas1@aol.com
The Cardinal Center for Healing - Fairfax, VA

Mary Anderson, PhD, ThD, LCSW
Director of The Cardinal Center for Healing in Fairfax, VA.
3919 Old Lee Highway
Suite 83A
Fairfax, VA 22030
Phone: 703-352-8535
Fax: 703-352-8805
email: mary.anderson@cardinalcenterforhealing.com
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