REGISTRATION FORM

Embrace the Sacred Within: A Women's Urban Retreat Day

https://www.missionempowerment.ca/embrace-the-sacred-within.html

Important Note: Please ensure that your email address is entered correctly; the email address provided will be used to send the confirmation of registration, receipt, and any necessary communication regarding this registration.

Workshop Title

Workshop Date (M/D/Y)

Date

Order Date (M/D/Y)

Date

Workshop Date & Time (for email)

Note dates and times and be sure to include ET. For example: Friday October 2nd and Friday October 9th, 2020 from 10am -1pm ET This auto-populates in the confirmation email from your entry above.

Education hours

Enter a number only (don't need to say "hours") such as 6.5 - this auto-populates in the confirmation email from your entry above. Education hours can be found in the event notes.

Recording Access length

Enter the time the recording will be avilalbe such as "60 days" or "2 weeks". This auto-populates in the confirmation email from your entry above. Recording access length can be found in the event notes.

M:E Email Address

This is just the "reply-to" email when we get jotform notifications.

Quantity of Tickets Required*

Buyer First Name*

Buyer Last Name*

Buyer Full Name*

Buyer Email Address*

Confirmation EmailPlease re-enter email address above to ensure accuracy

Country*

Street Address*

City*

Province*

Province/Territory/State*

Postal Code/Zip Code*

Buyer Cell Phone Number*

(Best Phone # to reach you in case of email issues)*

How did you hear about this event? Check all that apply:*

Registrant Information

Is Registrant # 1 the same person as the buyer?*

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Registrant # 1 First Name*

Registrant # 1 Last Name*

Registrant #1 Full Name*

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Registrant # 1 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

Registrant # 2 First Name*

Registrant # 2 Last Name*

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Registrant # 2 Cell Phone Number *

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

Registrant # 3 First Name*

Registrant # 3 Last Name*

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Registrant # 3 Cell Phone Number *

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

Registrant # 4 First Name*

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Registrant #4 Full Name*

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Registrant # 4 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

Registrant # 5 First Name*

Registrant # 5 Last Name*

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Registrant # 5 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

Registrant # 6 First Name*

Registrant # 6 Last Name*

Registrant #6 Full Name*

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Registrant # 6 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

Registrant # 6 Job Title*

Registrant # 6 Company/Organization*

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 7 First Name*

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Registrant # 7 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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Registrant # 7 Company/Organization*

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 8 First Name*

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Registrant # 8 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 9 First Name*

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Registrant # 9 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 10 First Name*

Registrant # 10 Last Name*

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Registrant # 10 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 11 First Name*

Registrant # 11 Last Name*

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Registrant # 11 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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Registrant # 11 Company/Organization*

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 12 First Name*

Registrant # 12 Last Name*

Registrant #12 Full Name*

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Registrant # 12 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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Registrant # 12 Company/Organization*

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 13 First Name*

Registrant # 13 Last Name*

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Registrant # 13 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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Registrant # 13 Company/Organization*

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 14 First Name*

Registrant # 14 Last Name*

Registrant #14 Full Name*

Registrant # 14 Email Address*

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Registrant # 14 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

Registrant # 14 Job Title*

Registrant # 14 Company/Organization*

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 15 First Name*

Registrant # 15 Last Name*

Registrant #15 Full Name*

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Registrant # 15 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

Registrant # 15 Job Title*

Registrant # 15 Company/Organization*

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 16 First Name*

Registrant # 16 Last Name*

Registrant #16 Full Name*

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Registrant # 16 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

Registrant # 16 Job Title*

Registrant # 16 Company/Organization*

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 17 First Name*

Registrant # 17 Last Name*

Registrant #17 Full Name*

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Registrant # 17 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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Registrant # 17 Company/Organization*

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 18 First Name*

Registrant # 18 Last Name*

Registrant #18 Full Name*

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Registrant # 18 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

Registrant # 18 Job Title*

Registrant # 18 Company/Organization*

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 19 First Name*

Registrant # 19 Last Name*

Registrant #19 Full Name*

Registrant # 19 Email Address*

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Registrant # 19 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

Registrant # 19 Job Title*

Registrant # 19 Company/Organization*

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

**Please note: Once payment has been processed, an automated confirmation email will be sent to the buyer and all attendees. To ensure you get this email and all emails from us about the event, please add info@missionempowerment.ca into your contact list in your email program. If you do not receive an email from info@missionempowerment.ca within a few minutes of registering, check your spam, junk and/or marketing folders. If found there, mark as "not spam" to restore to inbox so that your email program "learns" that we are a safe sender.

Important Instructions

Check off the box below and then select from the dropdown menu the specific number of tickets you are purchasing to match the number of registrants above. This will calculate your subtotal.

My Products*

Registration: Women's Urban Retreat Day in StratfordChoose the specific quantity of tickets from the dropdown menu to match the number of registrants above

$175.00CAD Quantity
Item subtotal:$0.00CAD

Enter coupon

Subtotal

$0.00CAD

Tax

$0.00CAD

Total

$0.00CAD

Payment Methods

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