Group Registration Form (10+ people)
Organizations registering groups of 10 or more people receive a discount of $30 off per person (before taxes) for a one-day workshop or $40 off per person (before taxes) for a two-day workshop.  Early-bird registrations only. Registrations must come altogether with one​ payment for the group. Discounts are only good for new registrations, and cannot be retroactively applied to registrations for which payment has already been processed.

Discounted Group Rate (10+ people) for 2-day “Adult Attachment in Clinical Practice" workshop:
$259 CAD + 13% HST (=$292.67) per person by October 29, 2020

Important Notes:
1) Please ensure that all email addresses are entered correctly; the email addresses provided will be used to send the confirmation of registration, receipt, and any necessary communication regarding this registration.

2) Please note that the attendee names entered on this form will be used for the sign in sheet and certificates of completion, exactly as entered. Please be sure to capitalize the first letter in the first name and last name, otherwise there will no be capitals on the certificate.

Payment options include credit card, Paypal or E-transfer.
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Workshop Title *
Buyer Name: *
Buyer Email Address: *
for confirmation and receipt
Organization Name: *
Organization Phone: *
Organization Mailing Address: *
Please enter FULL mailing address including postal code
How did you hear about this event? *
Check all that apply
Required
Terms & Conditions *
This session will be recorded and may be used for future projects. The event organizer retains all rights and permissions to use, distribute and promote these recordings. Recording will be of the main session only; it will not include breakout rooms.  Recording is set to “speaker view” so only those speaking on camera will be recorded.  If you choose to participate on camera and speak to the large group, you agree to be recorded.
Required
Cancellation Policy *
An administrative fee of $50 will be charged for all cancellations.  Cancellation 14 or more days prior to the workshop date – receive a refund, less $50 administration fee. Cancellation less than 14 days prior to the workshop date – receive a credit, less $50 administration fee, to be applied to a future workshop. No credit or refund will be issued if you do not notify us in advance of the workshop date. You may transfer your registration to another individual at no extra cost. In this case, please notify Mission: Empowerment of the name of the alternate person. The organizers reserve the right to cancel the event due to instructor illness, extreme weather, under-enrollment or other unforeseen circumstances. If a workshop is cancelled, any registration payment will be returned in full. Liability is limited to a refund of workshop/live-stream fees only.   **NOTE: If members of a group cancel, bringing the total number of participants below the threshold for the discounted group rate (10+ participants), the organization/buyer will be invoiced at the full rate for the remaining participants (or the 5-9 group rate if applicable).
Required
Please add me to your mailing list *
If you don't want to miss out on any of our fantastic professional development events or personal development workshops, sign up for our mailing list below.  We hold all events in Southwestern Ontario (usually Stratford or Kitchener) at venues with lots of FREE parking, and removed from the traffic headaches of the big city!
Registrant 1 Name: *
Registrant 1 Job Title: *
Registrant 1 Email: *
Registrant 1 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency): *
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 2 Name: *
Registrant 2 Job Title: *
Registrant 2 Email: *
Registrant 2 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency): *
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 3 Name: *
Registrant 3 Job Title: *
Registrant 3 Email: *
Registrant 3 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency): *
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 4 Name: *
Registrant 4 Job Title: *
Registrant 4 Email: *
Registrant 4 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency): *
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 5 Name: *
Registrant 5 Job Title: *
Registrant 5 Email: *
Registrant 5 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency): *
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 6 Name: *
Registrant 6 Job Title: *
Registrant 6 Email: *
Registrant 6 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency): *
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 7 Name: *
Registrant 7 Job Title: *
Registrant 7 Email: *
Registrant 7 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency): *
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 8 Name: *
Registrant 8 Job Title: *
Registrant 8 Email: *
Registrant 8 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency): *
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 9 Name: *
Registrant 9 Job Title: *
Registrant 9 Email: *
Registrant 9 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency): *
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 10 Name: *
Registrant 10 Job Title: *
Registrant 10 Email: *
Registrant 10 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency): *
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 11 Name:
Registrant 11 Job Title:
Registrant 11 Email:
Registrant 11 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency):
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 12 Name:
Registrant 12 Job Title:
Registrant 12 Email:
Registrant 12 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency):
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 13 Name:
Registrant 13 Job Title:
Registrant 13 Email:
Registrant 13 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency):
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 13: Please Specify Any Food Allergies or Dietary Restrictions and severity of allergic reaction if applicable (put N/A if not applicable):
Registrant 14 Name:
Registrant 14 Job Title:
Registrant 14 Email:
Registrant 14 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency):
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 15 Name:
Registrant 15 Job Title:
Registrant 15 Email:
Registrant 15 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency):
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 16 Name:
Registrant 16 Job Title:
Registrant 16 Email:
Registrant 16 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency):
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 17 Name:
Registrant 17 Job Title:
Registrant 17 Email:
Registrant 17 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency):
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 18 Name:
Registrant 18 Job Title:
Registrant 18 Email:
Registrant 18 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency):
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 19 Name:
Registrant 19 Job Title:
Registrant 19 Email:
Registrant 19 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency):
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
Registrant 20 Name:
Registrant 20 Job Title:
Registrant 20 Email:
Registrant 20 Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency):
Please enter just one phone number where you would be most likely to be reached on the morning of the event.
How will you be paying? *
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