AVP Workshop Registration Form

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Please note:
This updated registration form is for all AVP workshops/trainings being offered by AVPROCNY! We're excited to have you here! Unless you tell us otherwise, your photo may be used for future AVP publicity.

Email *

Today's date *

YYYY

Name (Last, First) *

Street Address *

City, State, Zip Code *

Phone number *

Email Address (Up-to-date) *

Age (Please note age restriction) *

Youth - No one under the age of 19 is allowed to participate in this set of Mini workshops

Teen (14-18) No one under the age of 19 is allowed to participate in this set of Mini workshops

Adult (19+)

Preferred method of contact *

Phone

Mail

Required

I am interested in taking: *

AVP Introductory Mini (Community Building/Not being offered at this time)

AVP Introductory Mini (Examining Buttons & Triggers/Not being offered at this time)

AVP Introductory Mini (March 21, 2024, 5:30 - 8:30 - Exploring and Healing and Forgiveness)

AVP In-Person Basic Workshop (Anticipated April 2024)

AVP In-Person Advanced Workshop (Anticipated May 2024)

AVP In-Person Training for Facilitators/T4F (Anticipated June 2024)

Other:

Required

I am interested in being contacted about the following workshops :

AVP Introductory "Mini" Workshop

AVP Basic Workshop

AVP Advanced Workshop

AVP Training for Facilitators (T4F)

AVP Special Topic Workshops

Cost for each Introductory "Mini" is $15.00, cost for EACH of the other 3 day workshops is $50. We believe that it is important to contribute something; however, NO ONE WILL BE TURNED AWAY for an inability to pay. If you are in need of a partial scholarship, please check that box. Under "Other", please fill in the amount you are able to afford. (You will be contacted after the registration form has been received). I am able to contribute: *

$15.00 USD (per each Mini)

$50.00 USD (per each workshop/Basic, Adv. and T4F)

I would like to be considered for a partial scholarship

I am willing to donate and help defray the cost of the workshop for those in need (any amount is appreciated!)

I would like a receipt for my donation

Other:

Required

I would like to be added to the AVP NY mailing list and give permission for the following contact information to be included from above : *

Email address

Phone number

Mailing address

No need, I am already on the mailing list ;-)

I do not wish to be added at this time

Facilitator Status: Please check the statement that is most accurate for you at this time. *

I have no experience facilitating AVP, I'm taking the workshop to explore that as an option.

I am familiar with AVP and am interested in becoming a certified AVP Facilitator.

I have completed this level of workshop before and I'm taking this training as a refresher.

I am taking this training as the first/next step toward becoming a certified AVP Facilitator

I am a certified AVP Facilitator and am participating out of a personal desire for more experience.

I am participating as a supporter/attendee for the workshop

Other:

Required

Is there anything that the team should be aware of that could impact your full participation in this workshop or training? If so, please explain under "Other": *

Yes

Other:

Required

Submit

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