Get Started
Please fill out this registration information and pay your $35 application fee. You will then have 14 days to complete the rest of the application information. If we reach capacity and aren't able to offer you a spot, we will refund your payment in full.
What is your name?
Participant Info
First Name
Last Name
Email
Date of Birth
Did you attend a workshop or info session before applying?
Yes
No
Are you under 18?
Yes
No
What is your address?
Address
Outside U.S.?
Street Address
City
State
Please select...
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Province/State
Zip/Postal Code
Country
Please note that by submitting this application you agree to be added to our mailing list. You may unsubscribe from our list at any time.
Would you (the participant) like to be added to our mailing list and receive updates and news from iBme?
Yes
No
Parent / Guardian
Parent Info
Parent First Name
Parent Last Name
We
require
you to provide both teen and parent email address - we like to be able to communicate directly with parents AND teens.
Parent Email
Parent address same as teen address?
Yes
No
Outside U.S.?
Parent Street Address
Parent City
Parent State
Please select...
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Parent Province/State
Parent Zip/Postal Code
Parent Country
Please note that by submitting this application you agree to be added to our mailing list. You may unsubscribe from our list at any time.
Would you (the parent) like to be added to our mailing list and receive updates and news from iBme?
Yes
No
Payment Info
Payment Info
Please select a payment method
credit card
check
Make check of $35 payable to
iBme, Inc.
and send to:
iBme, PO Box 516, Concord, MA 01742
The $35 application fee is nonrefundable except in cases where iBme determines a participant is not accepted into the retreat/program. Please confirm that you understand and agree to this policy.
I understand that the $35 application fee is nonrefundable except in cases where iBme determines a participant is not accepted into the retreat/program.
If the $35 application fee is a financial hardship for you, you may write to
registrar@ibme.com
to request an exemption. If requesting an exemption, please describe your particular circumstances in your email. If approved, you will be allowed to submit your application without having to pay the $35 application fee.
Billing First Name
Billing Last Name
Billing Email
Credit Card Number
Expiration Month
Please select...
01
02
03
04
05
06
07
08
09
10
11
12
Expiration Year
Please select...
2023
2024
2025
2026
2027
2028
2029
2030
CVV / CSC
Please consider covering the credit card processing fee for this transaction, which greatly helps to support iBme's operation costs.
Yes, please add 3% to my transaction to cover the credit card processing fee.
All transactions are securely processed through
Authorize.net
Application Fee: $
Credit Card Processing Fee: $
Total Current Payment: $
Calculated Fields
Description fields
Authorize.net Fields
Authnet_Hidden_Fields
GA Tracking Code
Contact Information