2023-24 Vermont Cohort Registration Form

Vermont Cohort Registration Form
Dates (all times in EST):

Three 3-Day in-person gatherings: Thursdays, 5PM - Saturdays, 3PM;
- Nov. 2-4, 2023
- Feb. 1-3, 2024
- May 2-4, 2024
Two evening calls: Thursdays, 6-8PM via Zoom
- January 11
- March 14
Name*

First NameLast Name
Prefer to be called
Email*
Phone Number*

Area CodePhone Number
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What draws you to participate in this Circle of Trust Cohort?*
What life questions are you holding at this time in your life?*
Please indicate any requests for accommodations or needs (meals/room/ accessibility):
Are you new to the cohort?*

YesNo
New participants will be contacted to cover any questions you may have as welcome.
How did you hear about this?*

WholeHeart EmailSocial MediaPersonal InviteOther

Payment
Overnight guest: $2,100

Day guest: $1,500

Payment can be paid in full at registration or in monthly installments. For monthly payment plans, an initial registration payment of $400 will reserve your spot for the year.

Partial scholarships are available. Please email Holly (holly@wholeheartinc.org) indicating the amount requested or with any questions before submitting your application. Your application will be saved and you can return to it at any time.

Payment selection: (select one option)

Overnight rate$2,100.00

*NOTE: all overnight guests will be assigned to a shared room with one other participant*

Overnight rate

Day rate$1,500.00

Day rate

Enter coupon

Total $0.00

Have you received a scholarship?*

YesNo
How much is your scholarship for?
Please include any additional billing details or requests:

Payment Methods

Debit or Credit Card

First Name

Last Name

Credit Card Number

Security Code

Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty: