scorpion_registrations

The Scorpion Time

First and Last Name

Address

City

State

Zip Code

Phone Number

Please enter Phone Number with dashes xxx-xxx-xxxx

Email

Confirm

The following information MUST be submitted to allow Judith to prepare your personal astrology chart for use in the class. By submitting this form you give Judith express permissions to use use this information for the stated purpose. NO INFORMATION WILL EVER BE MADE PUBLIC, SOLD, OR RELEASED.

Disclaimer: This course is not therapy, nor is it intended in any way as a substitute for therapy. Should emotional, psychological or physical issues become reactivated during this course, you are encouraged to consult with a qualified professional.

Please check the box to continue:

I agree to allow Judith to use my information

Date of Birth

mm/dd/yyyy
Example: 02/25/1951

Tme of Birth

Please be as accurate as possible

Place of Birth

City, State, County

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