Workshop Registration Form

First name:
Last name:
Street address:
Apt:
City:
State:
ZIP code:
E-mail address:
*Home phone:**
*Cell phone:**
*Work phone:**

*Unless you tell me otherwise, any phone messages I leave for you will be very discreet.

I wish to register for:

Social Anxiety Workshop
(for any adult who is socially anxious)
Friday, September 10, 2010 7-9 p.m.

Comments or questions (write below, or call Larry Cohen at 202-244-0903):

How did you find out about the workshops and the website?

If you receive an error message after submitting this form: Please go back to this page and write out all your information from this form in an email to me by clicking this link: Larry Cohen. Alternatively, you may also register by phone: 202-244-0903. Thank you.

YOU SHOULD RECEIVE AN EMAIL RESPONSE ACKNOWLEDGING YOUR REGISTRATION WITHIN 24 HOURS.

IF YOU DON'T, ASSUME THAT YOUR REGISTRATION WAS NOT RECEIVED AND PLEASE CONTACT ME RIGHT AWAY BY PHONE (202-244-0903) OR EMAIL Larry Cohen.

In addition, a confirmation packet will be mailed to your street address which will include workshop location, directions, and a set of questionnaires on social anxiety.

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