Empowering Youth, Starting with You: A Professional Development in Mindfulness

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Page 1

Inward Bound Mindfulness will keep confidential all information provided in this registration form except as required for participation in this program or as otherwise required by law.

Questions? registrar@inwardboundmind.org | (508) 250-0628

First Name

Last Name

Phone

Outside U.S.?

Street Address

City

State

Province/State

Zip/Postal Code

Country

Date of Birth (MM/DD/YYYY)

What is your gender?

What are your preferred pronouns? (Why do we ask this?)

Please list your pronouns.

What is their name?

What is the name of the studio or group?

What internet search term did you use?

Where did you find the ad?

Which social media service?

Inward Bound's email or someone else's?

Where did you hear about this program?

Occupation / career

Place of work

If you are a youth-serving professional, what age range do you work with?

Page 2

All fields are required. If a field does not apply, please write N/A.

What inspires you to attend this program?

Is there anything else you would like us to know about you, your mindfulness practice, or your motivation to attend this program?

Please acknowledge that you have completed this registration form in its entirety. (The next page is the payment page.)

I acknowledge that I have completed this registration form in its entirety.

Payment Details

Registration fees:

Early bird fee: $300 (Register by Aug. 29)

Standard fee: $350

Supporter fee: $400

Please specify your payment.

Early bird fee: $300 (Register by Aug. 29)Standard fee: $350Supporter fee: $400

Participating in "Bring A Friend?"

YesNo

Great! To qualify, the following must be met:

You *and* your friend both need to complete the registration form.
Input each other's names into the field here: "Friend's Name"
Attend this workshop.

A $50 discount is automatically applied to your registration fee. Looking forward to seeing you both at Empowering Youth!

Friend's Name

Deposit required to reserve your place

Please select current payment amount

Pay depositPay full tuition

Credit Card Details

Current payment amount

Billing First Name

Billing Last Name

Billing Email

Credit Card Number

Expiration Month

Expiration Year

Card Verification Value (CVV / CSC)

Please consider covering the credit card processing fee for this transaction, which greatly helps to support Inward Bound'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

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Cancellation Policy:

If you cancel by September 25, 50% of your payment will be refunded minus the admin fee of $75. We cannot offer refunds for cancellations made on September 26 or after. There is no refund if you decide to leave the program early.

Confirm that you have read and agree to our retreat cancellation policy above

I have read and agree to the cancellation policy for this retreat.

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Retreat Payment Amount: $

Credit Card Processing Fee: $

Total Current Payment: $

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Family member or friend	Inward Bound community member
Internet search	Internet ad
Social media	Email
Yoga/meditation group	Other