CHIP Reservation Form

* Indicates required field.

RESERVATION FORM CHIP 2010

Space is limited. Take advantage of this unique program and reserve your seat now! We look forward to seeing you at one of the FREE INFORMATIONAL sessions.

Name

First

Last

Spouse's Name (if attending the seminar)

First

Last

Mailing Address*

Address 1

Address 2

City

State

Postal Code

Country

Phone Number

E-mail Address

FeesPlease mark the appropriate selection.

$195/person

$325/with spouse sharing material

$100/returning alumni

$50/additional for Nurses CE Credit

Make Check payable to:

Lifestyle Plus-Lodi

Mail to:

Janis Effenberg, CHIP Registrar

1210 West Century Blvd., #9

Lodi, CA 95240

For Additional Information call:

Janis 209-365-7076

Irma 209-334-0200

Visit the CHIP Website: www.CHIPusa.org or www.sdachip.org