Name: ____________________________________ Credentials: ________________________
Place of Work: _________________________________________________________________
Professional Experience with Sexual Concerns: _____________________________________
_______________________________________________________________________________
Phone Number: ___________________________________________________________
Email Address: ____________________________________________________________
Payment: □ 40.00 (Registering before December 15th) □ 45.00 (After December 15th)
Saturday, January 16th, 2016 10-11:30 AM
Sexual Wellness Institute
18205 45th Ave N, Unit D
Plymouth, MN 55446
Please mail this registration form and a check payable to the Sexual Wellness Institute to the
following address:
18205 45th Ave N, Unit D
Plymouth, MN 55446
We look forward to seeing you!