Weight Loss Weekend Registration
First Name
Last Name
Email Address
Phone Number
Address
City, State Zip
Height
Sex
Male
Female
Age Group
15-17 (Need parental permission)
18-25
26-35
36-45
46-55
56-65
66-75
76+
Weight
Amount of weight desired to lose
Emergency Contact Name
Emergency Contact Number
I would like accomodation information
Yes
No
How did you hear about the conference?
Friend(s) attending
I am registering for...
2 Day Retreat (SAT & SUN)
1 Day Retreat (SAT only)
First Choice Breakout Session
Transformation Journal
Ayurveda: Yoga's Nutrition Plan
The Power of Self-Hypnosis
Weight Loss and Aging
Living through Pain
Emotional Eating
Becoming a Hyp-Yoga Instructor
Second Choice Breakout Session
Transformation Journal
Ayurveda: Yoga's Nutrition Plan
The Power of Self-Hypnosis
Living through Pain
Emotional Eating
Weight Loss and Aging
Becoming a Hyp-Yoga Instructor
Third Choice Breakout Session
Transformation Journal
The Power of Self-Hypnosis
Ayurveda: Yoga's Nutrition Plan
Emotional Eating
Living through Pain
Weight Loss and Aging
Becoming a Hyp-Yoga Instructor
Fourth Choice Breakout Session
Transformation Journal
Ayurveda: Yoga's Nutrition Plan
Weight Loss and Aging
The Power of Self-Hypnosis
Emotional Eating
Living through Pain
Becoming a Hyp-Yoga Instructor
Are you a fitness industry professional?
No
Yes
Payment Options
Credit Card Online
Check Mailed In
Print this page - mail in w/check
OK - mail ONLY if paying by check