REGISTRATION FORM
(Please copy, complete and mail or fax)

Living Awareness Foundation

phone: 610 565-5819 / fax: 610 565-1502
e-mail: jeanie@livingawarenessfoundation.com

“2010 – Birthing a New World!”
with Jeanie Bengtson, M.Ed.

Open to one and all!

Date: Tuesday, January 12, 2010
Time: 7:00 PM – 9:30 PM
Location:

Airport Ramada, Essington, PA
(just off I-95)
610-521-9600

$30 pre-registered; $40 if not

Name(s)___________________________________________________________________________

__________________________________________________________________________________
Address___________________________________________________________________________
City_______________________________________ State__________ Zip___________

Home Phone __________________________ Work Phone____________________

E-mail address________________________________________________________

Please reserve space for ___________persons. Amount $_________________

Check # _________________________ OR

Master Card / Visa #_____________________________________ Expiration (mm/yy) _____________

Please make checks payable to “Living Awareness Foundation” and mail to LAF,
Box 343, Wallingford, PA 19086

Your only acknowledgment will be your name tag at the admission door.

If you have any questions, please call 610 565-5819, fax: 610 565-1502 or e-mail: jeanie@livingawarenessfoundation.com