Dare To Lead - January Cohort 2024

Dare To Lead

January Cohort 2024 - Online
Registration is complete when you receive payment confirmation from PayPal.

Thank you for enrolling in the Dare To Lead program.
Your Name*

First NameLast Name
Your Nickname (if any)
Your Company Name
Your Title
Your Email*
Your Phone Number*

Area CodePhone Number
Billing address linked to your credit card*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Physical Mailing Address-for materials, (if different than billing address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guest Name

First NameLast Name
Guest Nickname (if any)
Guest Company Name
Guest Title
Guest Email
Guest Phone Number

Area CodePhone Number
Guest Physical Mailing Address-for materials, (if different than your mailing address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about this program??*

EmailSocial mediaWeb searchFriend or colleagueProfessional network or organization (please specify)Personal invitation from RMCPC consultantOther
If you heard about this program through a Professional network or organization, please tell us more here.
Payment is due at time of registration unless special circumstances have been pre-arranged with RMC.

We accept VISA, MasterCard, American Express and Discover. If you choose the “Payment Later” option, please explain in the Comment Box provided. All payments must be made in US Dollars.

If planning to pay using a Wire Transfer, please note in the Comment Box below and we will respond with an invoice and routing information within 3 business days. If your invoice needs to be copied to another email address, please note the email address, billing address, and billing instructions in the COMMENTS box below.

Payment is then due within 5 business days and before materials can be sent out.
Payment Method ( If you choose PAY NOW but do not complete the payment process and receive a PayPal receipt, the registration does not record.)

PAY NOW debit/creditSPECIAL CIRCUMSTANCES, PAY LATER
COMMENTS, PAY LATER Explanation and/or additional invoicing instructions (email address, mailing address (if different)
Select Option and Submit Payment*
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Early Bird Registration $1,400.00
Register by November 15 for the early bird rate.

Early Bird Registration- Nonprofit rate$1,150.00
Register by November 15 for the early bird nonprofit rate.

Registration$1,500.00
Standard rate after November 15.

Registration- Nonprofit rate$1,250.00
Nonprofit rate after November 15.

Total $0.00
CANCELLATION POLICY: Enrollment fee is non-refundable
I agree to the Cancellation Policy*

Yes
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