Elements Registration — WESPINE STUDY CENTER

Please complete the below form to apply to The Elements

The seminar costs $230 per participant. Interested students must submit the application with a non-refundable deposit of $20. Applications received a month or more in advance qualify for a $50 discount.

Financial considerations should not prevent anyone from attending. Please inquire about scholarships.

Father's Name

First Name

Last Name

Mother's Name

First Name

Last Name

Son's Name

First Name

Last Name

School

Grade

Optional: other children and their ages

This will help Wespine keep you informed about possible programs in the future.

Street Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone Number

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Father Cell Phone

(###)

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Mother Cell Phone

(###)

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Student Cell Phone

(###)

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Father Email Address

Mother Email Address

Student Email Address

Reference (Who recommended this program to you?)

Comments