Registration

Print and send registration to:

    Whidbey Institute / Practice of Peace

     P.O. Box 57

    Clinton, WA 98236

You can also fax the registration to 360.341.1899 or e-mail it to Mary Ella Keblusek at maryella@pobox.com.

Name:________________________________________________________________

Organization:___________________________________________________________

Street:________________________________________________________________

City:__________________________ State:                   ZIP/Postal Code:                              

Country:  ________________________________

Phone:________________________   Fax:  __________________________________

Email:                                                                                                                                               

Please circle your pricing:   

With organizational support: $750
Non-profits & without organizational support: $450
Students: $350
Single Day Rate: $175
    Which day(s) (circle)? November   9    10    11    12

CREDIT CARD INFORMATION

Cardholder (if different from above):  __________________________________________

Card type (Mastercard, VISA, American Express):  ____________________  

Card number:  ____________________________    Expiration date (MM/YY):  __________

Alternatively, please mail a check or money order in U.S. dollars with your registration information.