Registration for the Emotional Clearing Workshop with John Ruskan

name:
first, last
street address:
  
city, state, zip:
  
phone:
  
credit/debit card type:
 Visa or Mastercard only
card number:
  
card expiration date:
  
email:
  
please re-enter email:
 We need 2 email entries because the data goes to 2 places
any questions:
Your card will be charged $225 and you will be notified
by email when we reach our minimum number of participants.