Empowering Wellness Initiative Registration Form: Individual
We are excited that you have chosen to join us for our Empowering Wellness Initiative! It is not easy to make ourselves a priority. Well done in taking this first step towards improving your overall wellness!
Personal Information
Name
First Name
Last Name
Email
example@example.com
Is there a positive habit that you want to establish in the coming months?
What do you currently do, or would you like to do, for self-care? What activities contribute to your overall wellness?
How did you hear about the LSTS Empowering Wellness Initiative?
Payment
Payment Method
I identify as from a historically marginalized community (you may participate for free for one month).
My employer is covering the tab! (If you register as an individual and your employer signs up later you will be reimbursed)
You may pay by check if you reside in MN. Please contact melissa@livingspirittherapy.com if you would like to pay by check
Credit Card. Use the secure form below for credit card payments.
Name of employer with company enrollment
If your employer is covering the tab or your are paying by check you don't need to complete the bottom section of this form. Continue if you are paying by credit card.
Rates
Individual Registration Rate $50.
Enter $50 in this Field
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USD
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Phone Number
-
Area Code
Phone Number
Submit
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