Michigan Brain Gym® Consortium Class Registration
Please print, complete mail or fax along with your payment/info to:
The Michigan Brain Gym® Consortium
PO Box 3339, Grand Rapids, MI 49501
Fax: 1-616-233-9494
For Internal Use Only
Received______
Processed______
Entered______
Confirmation______
Name____________________________________________________
Address___________________________________________________
City______________________State_____________ZIP____________
School/Organization if applicable: ______________________________
Work Phone_______________________________________________
Home Phone_______________________________________________
Cell Phone_________________________________________________
Email____________________________________________________
Name of Class_____________________________________________
Date of Class______________________________________________
Amount Enclosed___________________________________________

Payment Method:

Check, #______________________

Credit Card:          Visa     MC     AMEX    

Card Number_______________________________________________

Expiration_______________________ Sec. Code___________________

Signature__________________________________________________