REGISTRATION FORM FOR RAW FOOD SERVICES BY JACQUELINE D. ROOTHS
Print out this form and mail in along with your payment. Class size is limited; early registration is recommended to secure your space.

Name: ____________________________________ Email: _________________________

Address: _________________________________________________________________

City: ______________________________ State: _____________ Zip:_________________

Area Code/Phone (day):________________________ (evening): ______________________

   I would like to receive notification about upcoming courses and classes by email.

Date(s) of the event(s) I'm registering for ______________________________________________
Registration for (select all that apply):

_____ Journey to Self 2-Part Workshop - 65.00

_____Alissa Cohen Living on Live Food Level One Class- 125.00

_____ Alissa Cohen Living on Live Food Level Two Class - 650.00

_____Private One-On-One Raw Food Class - 300.00

_____30-Minute Initial Consultation - 30.00

_____One Hour Initial Consultation - 50.00

My check*/money order for $ ___________ is enclosed, payable to:

Jacqueline D. Rooths.
14690 Gallant Lane
Waldorf, Maryland 20610

*Personal checks are accepted, however, there is a $35.00 check fee for any returned checks.
Receipts for payments are e-mailed to the individual upon receipt.