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

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

Should be Empty: