To Whom I May Concern® Facilitator Training 2023

To Whom I May Concern® Facilitator Training

Spring 2023
Personal Information
Full Name*

PrefixFirst NameLast Name
Organization
Your Position
E-mail*
Phone Number*

Area CodePhone Number
Mobile Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Do you currently or have you previously facilitated a support group for people living with dementia?

YesNo
Please tell us about your experience facilitating a support group or other group involving people living with dementia:
Do you plan on holding a To Whom I May Concern® performance in your community within 6 months of the training?

YesNo
Use this field to tell us anything you think would be helpful to us about your plans for To Whom I May Concern in your community and/or your current work with people living with dementia.
Other Trainees from Same Organization
1st Trainee

PrefixFirst NameLast Name
Organization
Position
E-mail
2nd Trainee

First NameLast Name
Organization
Position
E-mail

Please choose one of the following options. Payment is processed through PayPal.

Registration Fee:$500.00

Registration Fee (with 1 additional trainee from same organization):$900.00

Registration Fee (with 2 additional trainees from same organization):$1,350.00

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Total $0.00

If you would like us to invoice your organization, please submit the company name and contact information below.
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To Whom I May Concern® Facilitator Training