Stress Reduction - Registration Page

Employee Assistance Services
With you every step of the way.

Life Management Associates
 1848 Charter Lane
Lancaster, PA  17601
info@LMA-EAP.com

The Healing Power of Sound, Breath and Meditation
REGISTRATION
Saturday, May 15, 2010 (10AM-4:30PM)

Online Registration - Complete form below and submit.
Phone Registration - 717.394.6688 / 800.327.7770

Please complete registration form.  All information is confidential.

First Name
Middle Initial
Last Name
Street Address
City
State
Zip
Home Phone (with area code)
Work Phone (with area code)
Cell (with area code)
Email (class confirmation/changes will be made via email
Employer / School

Cost:  $75 per person or if you work for a company with an LMA EAP, you may use one EAP session.

Method of Payment:
 - Check (payable to Life Management Associates.  Please note in Memo:  "Healing Power Workshop")
 - Credit Card (to use your credit card, call LMA office at 394-6688)
 - EAP session

IF YOU ARE USING YOUR LMA EAP TO ATTEND, PLEASE COMPLETE THE FOLLOWING SECTIONS:
(if not using EAP sessions, click on the submit button at the bottom of this page)

Birthdate:
Gender:
Years Employed by Organization:

CHECK ONLY ONE IN EACH CATEGORY:

Referral Source
Self
Management (Mandatory)
Management (Suggested)
Union
Medical
Employer / Human Resources
Family
Co-Worker / Friend
Managed Care Program
Other / Unknown
Advertisement (please specify)

Education Completed
Young child (not yet in school)
Preschool / Kindergarten
Grade School
Some High School
High School Graduate
GED
Trade / Technical School
Some College
Associates Degree
Some Graduate School
Graduate Degree
Some Post Graduate
Post Graduate Degree

Marital/Relationship Status
Single
Married
Divorced
Separated
Widow / Widower
Cohabitating

Ethnic Origin
Black / African American
Hispanic
Asian / Pacific Islander
Native American
Caucasian
Other
Job Category
School Employees:
School Administration
School Middle Mgmt / Dept Head
School Teacher
School Salaried (other than teacher)
School Hourly
Other Employees:
Executive
Management
Supervisor / Line Leader
Professional
Technical
Administrative
Outside Sales
Skilled Labor / Craftsperson
Service
General Labor
Other / Unknown / NA

If you are a family member of an employee who has Employee Assistance Program (EAP) benefits, complete this section about the employee:

Name
Street Address
City
State
Zip
Home Phone
Work Phone
Date of Birth
Employer
Relationship to Employee:
Spouse
Child
Stepchild
Parent
Other
Marital Status
Single
Married
Divorced
Separated
Widowed
Cohabitating
Gender
Male
Female
Education Completed (check highest level completed)
Young child (not yet in school)
Preschool / Kindergarten
Grade School
Some High School
High School Graduate
GED
Trade / Technical School
Some College
Associates Degree
Some Graduate School
Graduate Degree
Some Post Graduate
Post Graduate Degree

 

 

Submit Your Registration - Thank you.