Collage Art Therapy Registration

Collage Art Therapy Registration

Our weekly Collage Art Therapy workshop is held most Thursdays at 2pm in our conference room (3611 River Road, Ste 200, Yakima, WA 98902). Please have each person who is planning on attending submit a separate form so we can plan accordingly. Thank you!
Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Which Collage Art Therapy workshop(s) are you attending? (select all that apply)*

Thursday, March 13 at 2pmThursday, March 20 at 2pmThursday, March 27 at 2pmThursday, April 3 at 2pmThursday, April 10 at 2pmThursday, April 17 at 2pmThursday, April 24 at 2pm
Are you a current member with Assurance Healthcare & Counseling Center?*

YesNoI'm not sure
By clicking the submit button below, you agree to have the above information sent securely via this HIPAA compliant form to another third-party application managed by Assurance Healthcare & Counseling Center where private data is securely stored. Any identifying PHI (protected health information) will not be transmitted via email or any other insecure format.
Should be Empty: