REGISTRATION FORM

Psilocybin-Assisted Therapy

https://www.missionempowerment.ca/psilocybin-assisted-therapy.html

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

Workshop Title

Workshop Date (M/D/Y)

Date

Order Date (M/D/Y)

Date

Workshop Date & Time (for email)

Note dates and times and be sure to include ET. For example: Friday October 2nd and Friday October 9th, 2020 from 10am -1pm ET This auto-populates in the confirmation email from your entry above.

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.

Recording Access length

Enter the time the recording will be avilalbe such as "60 days" or "2 weeks". This auto-populates in the confirmation email from your entry above. Recording access length 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*

(for 20 or more please contact us at info@missionempowerment.ca for a group registration form)

Do all registrants work for the same company?*

YesNo

Buyer First Name*

Buyer Last Name*

Buyer Full Name*

Buyer Email Address*

Confirmation EmailPlease re-enter email address above to ensure accuracy

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*

Province/Territory/State*

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

This session will be recorded and may be used for future projects. The event organizer retains all rights and permissions to use, distribute and promote these recordings. Recording will be of the main workshop only; it will not include breakout rooms. Recording is set to “speaker view” so only those speaking will be recorded. If you choose to speak during the main workshop session, you agree to be included in the recording.

Workshop access is restricted to one person per ticket purchased.

Cancellation Policy

An administrative fee of $50 will be charged for all cancellations. Cancellation 14 or more days prior to the workshop date – receive a refund, less $50 administration fee. Cancellation less than 14 days prior to the workshop date – receive a credit, less $50 administration fee, to be applied to a future workshop. No credit or refund will be issued if you do not notify us in advance of the workshop date. You may transfer your registration to another individual at no extra cost. In this case, please notify Mission: Empowerment of the name of the alternate person. The organizers reserve the right to cancel the event due to instructor illness, extreme weather, under-enrollment or other unforeseen circumstances. If a workshop is cancelled, any registration payment will be returned in full. Liability is limited to a refund of workshop/live-stream fees only.

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 at least 24 hours prior to the start time of the workshop.

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*

example@example.com

Registrant # 1 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 # 1 Job Title*

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*

Registrant # 2 Last Name*

Registrant #2 Full Name*

Registrant # 2 Email Address*

example@example.com

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): *

Registrant # 2 Job Title*

Registrant # 2 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 # 3 First Name*

Registrant # 3 Last Name*

Registrant #3 Full Name*

Registrant # 3 Email Address*

example@example.com

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): *

Registrant # 3 Job Title*

Registrant # 3 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 # 4 First Name*

Registrant # 4 Last Name*

Registrant #4 Full Name*

Registrant # 4 Email Address*

example@example.com

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): *

Registrant # 4 Job Title*

Registrant # 4 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 # 5 First Name*

Registrant # 5 Last Name*

Registrant #5 Full Name*

Registrant # 5 Email Address*

example@example.com

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): *

Registrant # 5 Job Title*

Registrant # 5 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 # 6 First Name*

Registrant # 6 Last Name*

Registrant #6 Full Name*

Registrant # 6 Email Address*

example@example.com

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): *

Registrant # 6 Job Title*

Registrant # 6 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 # 7 First Name*

Registrant # 7 Last Name*

Registrant #7 Full Name*

Registrant # 7 Email Address*

example@example.com

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): *

Registrant # 7 Job Title*

Registrant # 7 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 # 8 First Name*

Registrant # 8 Last Name*

Registrant #8 Full Name*

Registrant # 8 Email Address*

example@example.com

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): *

Registrant # 8 Job Title*

Registrant # 8 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 # 9 First Name*

Registrant # 9 Last Name*

Registrant #9 Full Name*

Registrant # 9 Email Address*

example@example.com

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*

example@example.com

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): *

Registrant # 10 Job Title*

Registrant # 10 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 # 11 First Name*

Registrant # 11 Last Name*

Registrant #11 Full Name*

Registrant # 11 Email Address*

example@example.com

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): *

Registrant # 11 Job Title*

Registrant # 11 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 # 12 First Name*

Registrant # 12 Last Name*

Registrant #12 Full Name*

Registrant # 12 Email Address*

example@example.com

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): *

Registrant # 12 Job Title*

Registrant # 12 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 # 13 First Name*

Registrant # 13 Last Name*

Registrant #13 Full Name*

Registrant # 13 Email Address*

example@example.com

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): *

Registrant # 13 Job Title*

Registrant # 13 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 # 14 First Name*

Registrant # 14 Last Name*

Registrant #14 Full Name*

Registrant # 14 Email Address*

example@example.com

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): *

Registrant # 14 Job Title*

Registrant # 14 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 # 15 First Name*

Registrant # 15 Last Name*

Registrant #15 Full Name*

Registrant # 15 Email Address*

example@example.com

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): *

Registrant # 15 Job Title*

Registrant # 15 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 # 16 First Name*

Registrant # 16 Last Name*

Registrant #16 Full Name*

Registrant # 16 Email Address*

example@example.com

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): *

Registrant # 16 Job Title*

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*

example@example.com

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*

Registrant # 17 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 # 18 First Name*

Registrant # 18 Last Name*

Registrant #18 Full Name*

Registrant # 18 Email Address*

example@example.com

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*

Registrant # 18 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 # 19 First Name*

Registrant # 19 Last Name*

Registrant #19 Full Name*

Registrant # 19 Email Address*

example@example.com

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)

**Please note: Once payment has been processed, an automated confirmation email will be sent to the buyer and all attendees. To ensure you get this email and all emails from us about the event, please add info@missionempowerment.ca into your contact list in your email program. If you do not receive an email from info@missionempowerment.ca within a few minutes of registering, check your spam, junk and/or marketing folders. If found there, mark as "not spam" to restore to inbox so that your email program "learns" that we are a safe sender.

Important Instructions

Check off the box 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.

My Products*

Early-Bird Registration: Psilocybin-Assisted Therapy WorkshopChoose the specific quantity of tickets from the dropdown menu to match the number of registrants above.

$99.00CAD Quantity
Item subtotal:$0.00CAD

Enter coupon

Subtotal

$0.00CAD

Tax

$0.00CAD

Total

$0.00CAD

Payment Methods

Debit or Credit Card

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Credit Card Number

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