The Fire Energy Experience - Printable Registration Form
Sat June 25th 2011 Firewalk

In order to register into The Fire Energy Experience Seminar, Please fill out the form below. Attach a check/money order payable to Balancing Act or fill in your credit card number/expiration date (Visa & M/C Only) and send to the address below. You can also Fax it, but please call 1st, because we don’t have a dedicated Fax, we receive it manually on our computer. If you are running close to one of the deadlines, you can call in your Credit Card info, and then send in the form. Be sure you send the correct amount of funds by or before the cut off dates or there may be a balance due. As soon as payment has been received we will send you a confirmation letter with directions to the location of the event. For those that register late, confirmation/directions will be done by phone, fax or email. (One Form Per Person-Minors Need Parent’s Permission)



Address (mailing)_________________________________________________

City_________________________State_______Zip Code________________



Enclosed is $85.00 (By June 6th), $95 (By June 17th) $110.00 there after

Firewalk Graduates: Take $10 off the above fees (16 yrs and under go 1/2 price).

Check /Money Order Or charge to my Visa_____MC______

Credit Card#________________________________________________


By registering into this seminar, I understand that I will be responsible for any balance due and prepaid fees are non refundable unless the event is cancelled. I will be required to read and sign a release form. The actual firewalk is optional and is not a requirement to attend this seminar. Only people that are registered and paid will be admitted, no outside observers, please.

Please print and fill out this form completely and send or *fax to the address below.

Make checks payable & send to: Balancing Act, Box 462 Charlestown, RI. 02813
Checks must be paid or post marked on or before the prepaid dates-no exceptions.
Comfirmation and directions will be sent via email, snail mail or fax .

*Call the number below before faxing, we do not have a dedicated fax machine.

(401) 364-3600
Return to Form Page