East West Rehabilitation Institute
Integrative Breath-Work: East & West, MInd and Body

Memorial Sloan-Kettering Cancer Center
New York City
October 14-15 ^th 2006

Please TYPE or PRINT your name and as it should appear on your continuing education certificate.

---

Name__________________________________________________________________________________________
                                                                                         First, Last

Professional Initials _________________________ Home Tel (        )____________________

Home Address ___________________________ City/State/Zip _______________________________


Facility _____________________________________________________________________________________________


Work Tel (        ) ___________________________ Fax (        ) ________________________________


Work Address _________________________ City/State/Zip __________________________


Position _____________________________________________________________________________________________


E-mail address: _____________________________________________________________________________________________

Make checks payable to:
East West Rehabilitation Institute
$375 ($360 if recieved by 10/1/06)

Send to:
East West Rehabilitation Institute

360 Cabrini Blvd, Suite 3B

New York,NY 10040