REGISTRATION FORM


Imago Weekend Workshops

 Presented by Dr. Teresa M. Hunt, Ph.D. Licensed Psychologist, Imago Therapist
Imago Couples Workshop Presenter

Conte Lubrano Building, 130 Lubrano Drive, Annapolis, MD
Lower Level Meeting Room

~ Please check  the schedule of upcoming workshops  on the home web page
and indicate your preferred workshop, date and fee below ~

Title of Workshop:                                                                                      

Preferred Date of Workshop: ______________________________________

Fee for workshop:                                                                    

Name: (as it appears on Credit Card)                       Name/Nickname to appear on badge:

______________________________________   ________________________________

Billing Address:_________________________________________________________

_______________________________________________________________________

Phone: ____________________________ Email: ______________________________
 

Credit Card Type:_________   Card Number:_________________________________

Expiration Date:__________   Three Digit Code on Back:_________  

Partner’s Name:                             Name/Nickname to appear on badge:

______________________________________   ________________________________

Partner’s                        Partner’s

Phone: __________________________  Email:________________________________

To register by mail, return this form with credit card information or check to:

                                           Dr. Teresa M. Hunt, PhD             
                                            1438 Ridgeway East
                                            Arnold, Maryland 21012

To register by phone please call Dr. Hunt’s office:    410.757.1176
Or email your information to drtmhunt@gmail.com.