MindFood Learning Exchange

The MindFood Learning Exchange Registration Form

Print out form and Mail To: 6333 Belair Rd Or Fax to:410-510-1489

Baltimore, Md 21212

Name:_________________________________________Member #_______________

Occupation___________________________Email _____________________________

Address________________________________________________________________

City_______________________________State___________Zip__________________

Day Phone__________________________Night Phone_________________________

course#	Name	Course Date	Fee






Add Non-Member monthly processing fee ( Non-Members Only)			$ 6.00
Materials Fee is Paid Directly to instructor at Total Time of first class

ENCLOSE A CHECK MADE PAYABLE TO MINDFOOD LEARNING EXCHANGE

OR ENCLOSE CREDIT CARD INFORMATION

I hereby authorize the use of my MasterCard or Visa:

Signature____________________________________________

Credit Card#____________________________________ Pin #____________

( 3-digit code on back of card)

Name on Credit Card________________________________

Expiration Date/ Month_______________ Yr__________