Empower ThyselfRegistration Form Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Are you ok with us contacting you via email with newsletters, updates and offerings? * I am I am not Phone * (###) ### #### Date of Birth MM DD YYYY Class Date * MM DD YYYY Will you be attending? * Yes No Have you previously worked with a practitioner in the Modern Mystery School? Yes No If yes, with whom> MMS Student Number Thank you!
