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Name:_______________________________________________________________________________

Phone: Home:_____________________  Work: _____________________   Cell: ____________________

Print this page and return the form with your check:
Hillary Blackton
Divine Life Yoga
19008 High Point Drive
Gaithersburg, MD 20879-3402

Call Hillary Blackton at 301-924-5164 or email hillary@divinelifeyoga.com if you have any questions.