Forms

Access the forms you need below then fill out and submit it to us either by fax (504) 309.5224 or scan back to coupleslifecoach@gmail.com. 

For the Workshop Form, there is a $100 discount if registered two weeks prior to workshop (September 3, 2019). You may also email Dr. Ashkins to request a copy of our brochure.

“Mindful Love” Registration

with Dr. Cindy Ashkins

WORKSHOP REGISTRATION FORM

PERSONAL INFORMATION:

 

Today’s Date:                                          

 

Name 1:                                                                                                                                 

 

Name 2:                                                                                                                                 

 

Address:

                                                                                                                                

 

City:                                                State:                     Zip:                                  

 

Cell #1:                                     _

Cell #2:

 

Email Address:                                                                                                                     

 

Referred by:

 

PAYMENT INFORMATION:

 

Amount Paid:$                                            Amount Due:$                         

Check           

Visa           

MasterCard           

AmEx           

Venmo_____

 

Name on Card:

                                                                                                                      

 

Billing Address (if different from above):                                                                                         

 

City:                                                    State:                     Zip:                                  

 

Card Number:                                                               Expiration:____/_______

Security Code:                Signature:                                                   __

 

Make checks payable to: Dr. Cindy Ashkins

121 Metairie Lawn Drive, Suite A

Metairie, LA 70001

 Or fax completed form to: 504.309.5224/email: Coupleslifecoach@gmail.com

 

Workshop: $750. Deposit required for registration: $300

Early Bird Registration $100 Discount if registered by September 3, 2019.

Due to Dr. Ashkins’ need to order and print workshop materials, please cancel within 7 days of the workshop or your deposit will be forfeited or may be used for later workshops.

Mindful Love Registration 2019