January 2019 Registration Group Detox Registration Name* First Last Meal Delivery Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneEmail* Dietary Restrictions?I plan on attending the following meetings:* Friday, January 4th: 11am - 12:30pm Thursday, January 17th: 11am - 12:30pm I would like to be in the same group as:How did you hear about my Group Detox Program? Friend / Word of Mouth Tracy Bechtel Wellness Newsletter Posted Flyer Online Search Facebook / Instagram Other If "Other", where did you hear about my Program? Δ Go To Cooking Assignments
