REGISTRATION FORM

Motivational Interviewing: ON DEMAND

https://www.missionempowerment.ca/motivational-interviewing-on-demand.html

Before completing this form, please note:

After you have completed registration and payment, emails will be automatically sent with your webinar access instructions.

To ensure these emails get to you, please do the following PRIOR to completing and submitting this form:

Add the following email addresses into your contact list in your email program (for the email address you will be registering with):

This helps to make sure our emails don't get blocked or redirected to spam, junk and/or marketing folders.

Please ensure that your email address is entered correctly below; the email address provided will be used to send the confirmation of registration, receipt, webinar access, and any necessary communication regarding this registration.

Workshop Title

Order Date (M/D/Y)

Date

Education hours

Enter a number only (don't need to say "hours") such as 6.5 - this auto-populates in the confirmation email from your entry above. Education hours can be found in the event notes.

M:E Email Address

This is just the "reply-to" email when we get jotform notifications.

Quantity of Tickets Required*

(Please note: Workshop access is restricted to one person per ticket purchased).

Do all registrants work for the same company?*

YesNo

Buyer First Name*

Buyer Last Name*

Buyer Full Name*

Buyer Email Address*

example@example.com

Buyer Job Title*

Buyer Company Name *

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Country*

Street Address*

City*

Province*

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Postal Code/Zip Code*

Buyer Cell Phone Number*

(Best Phone # to reach you in case of email issues)*

How did you hear about this event? Check all that apply:*

Which website? Check all that apply:*

Speaker's websiteEEnet ConnectCanadian Addiction Counsellors Certification Federation (CACCF) websiteCanadian Counselling & Psychotherapy Association (CCPA) websiteMedical Psychotherapy Association of Canada (MDPAC) websiteCAOT websiteMission: Empowerment! websiteOther

Terms & Conditions

Webinar access is restricted to one person per registration purchased. Seat sharing is strictly prohibited.

Webinar access and all associated materials (handouts, resources, quiz etc) will expire in 365 days from date of purchase.

The use of recording devices or software to copy content for personal or professional use, in any format, is strictly prohibited. Distribution of the webinar recording will result in immediate termination of access. Mission: Empowerment reserves the right to seek compensation from anyone who violates these terms and conditions. Please note: webinar access is monitored for suspicious activity.

Cancellation: There are no refunds/credits for on-demand workshops as you have a full year to view the course. Refunds will not be issued in cases where a registrant did not receive the workshop login instruction email due to email issues. It is the registrant’s responsibility to contact us if they don’t receive the required login information in a timely manner (i.e. by end of day the next business day).

Please check the box below to confirm that you understand and agree to the terms & conditions. This form will not allow payment to go through if you do not check off the box below.

Email List

Yes, add me to your email list to be informed of other upcoming events

Registrant Information

Is Registrant # 1 the same person as the buyer?*

YesNo

Registrant # 1 First Name*

Registrant # 1 Last Name*

Registrant #1 Full Name*

Registrant # 1 Email Address*

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Registrant # 1 Cell Phone Number*

(Best Phone # to reach you in case of email issues) *

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Registrant # 1 Company/Organization*

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 2 First Name*

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Registrant # 2 Cell Phone Number *

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 3 First Name*

Registrant # 3 Last Name*

Registrant #3 Full Name*

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Registrant # 3 Cell Phone Number *

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 4 First Name*

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Registrant # 4 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 5 First Name*

Registrant # 5 Last Name*

Registrant #5 Full Name*

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Registrant # 5 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 6 First Name*

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Registrant # 6 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 7 First Name*

Registrant # 7 Last Name*

Registrant #7 Full Name*

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Registrant # 7 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 8 First Name*

Registrant # 8 Last Name*

Registrant #8 Full Name*

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Registrant # 8 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 9 First Name*

Registrant # 9 Last Name*

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Registrant # 9 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

Registrant # 9 Job Title*

Registrant # 9 Company/Organization*

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 10 First Name*

Registrant # 10 Last Name*

Registrant #10 Full Name*

Registrant # 10 Email Address*

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Registrant # 10 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 11 First Name*

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Registrant # 11 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 12 First Name*

Registrant # 12 Last Name*

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Registrant # 12 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 13 First Name*

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Registrant # 13 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 14 First Name*

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Registrant # 14 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 15 First Name*

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Registrant # 15 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 16 First Name*

Registrant # 16 Last Name*

Registrant #16 Full Name*

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Registrant # 16 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

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Registrant # 16 Company/Organization*

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 17 First Name*

Registrant # 17 Last Name*

Registrant #17 Full Name*

Registrant # 17 Email Address*

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Registrant # 17 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

Registrant # 17 Job Title*

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 18 First Name*

Registrant # 18 Last Name*

Registrant #18 Full Name*

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Registrant # 18 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

Registrant # 18 Job Title*

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(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Registrant # 19 First Name*

Registrant # 19 Last Name*

Registrant #19 Full Name*

Registrant # 19 Email Address*

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Registrant # 19 Cell Phone Number*

(Best Phone # to reach you on the MORNING of the workshop in the unlikely event of cancellation or emergency on the day of the event): *

Registrant # 19 Job Title*

Registrant # 19 Company/Organization*

(If in Private Practice or Self Employed without a company name, please write "Private Practice" or "Self Employed". If not employed, please just enter your full name in this box)

Important Instructions

Check off the box below and then select from the dropdown menu the specific number of tickets you are purchasing to match the number of registrants above. This will calculate your subtotal.

Checkout*

Registration: Motivational Interviewing Workshop ON DEMANDChoose the specific quantity of tickets from the dropdown menu to match the number of registrants above.

$349.00CAD Quantity
Item subtotal:$0.00CAD

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Subtotal

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