holotropic breathwork™ registration form

™™™™™™ Holotropic Breathwork dates TBA

Name:______________________________________ Phone: ( )_________________________


E-mail: _____________________________________________ Date:_____________________

Is this your first Holotropic Breathwork? __ Yes __ No

____$75 deposit (cash balance due by date of workshop)

____$120 postmarked 14 days before workshop OR ____$135 postmarked after that date OR

____$125 Pay Pal for Dori ____$141 Pay Pal for Dori

By registering for this workshop, I understand the medical contraindications and I acknowledge that they do not apply to me. I also understand and accept the payment and refund policy.


Signature Date

Please send a check payable to Dori Langevin or PayPal with this signed registration form to:
Dori Langevin 4612 S. Schafer Branch Rd, Spokane, WA 99206