In order to register into The Firewalking America Seminar, Please fill out the form below. Attach a check/money order payable to Marcie Mendez or fill in your credit card number/expiration date (Visa & M/C Only) and send to the address below. You can also Fax your credit info to 727-217-4996. If you are running close to one of the deadlines, you can call in your Credit Card info, and then send in the form. Be sure you send the correct amount of funds by or before the cut off dates or there may be a balance due. As soon as payment has been received we will send you a confirmation letter with directions to the location of the event. For those that register late, confirmation/directions will be done by phone, fax or email. (One Form Per Person-Minors Need Parent’s Permission)

Name___________________________________________

Company________________________________________

Address (mailing)_________________________________________________

City_________________________State_______Zip Code________________

Phone-Day________________________Evening_______________________

Fax_________________________Email______________________________

Enclosed is $99.00 (new walker), $99.00 (Repeat walker )

Firewalk Graduates: Take $10 off the above fees (16 yrs and under go 1/2 price).

Check /Money Order Or charge to my Visa_____MC______

Credit Card#________________________________________________

Expires__________Signed_____________________________________

By registering into this seminar, I understand that I will be responsible for any balance due and prepaid fees are non refundable unless the event is canceled. I will be required to read and sign a release form. The actual firewalk is optional and is not a requirement to attend this seminar. Only people that are registered and paid will be admitted, no outside observers, please.