CCE Retreat Registration

Page 1

Has CQ

TRUEFALSE

Modality

OnlineIn-personHybrid

The retreat will begin at 5 p.m. on Tuesday and conclude at 1 p.m. on Friday.

Location: St. Andrew’s House, 7550 WA-106, Union, WA 98592

This retreat is open to those who identify as women, and is designed to help participants renew their passion, enthusiasm and commitment to their leadership and the communities they serve.

Registration Type

First Name

Last Name

Chosen First Name

Chosen Last Name

Date of Birth

MM/DD/YYYY - Used to match registrant records

Phone

Email

This email address will be used for all retreat communications.

Re-type email

ZIP/Postal Code

How did you hear about this event?

Please elaborate

Would you like to subscribe to our:

Monthly Newsletter

event type subscription ceu

Counseling Psychology Mailing list

event type subscription pdu

Teacher Education Mailing list

event type subscription transactive

TransActive mailing list

event type subscription psilocybin

Non-Ordinary States of Consciousness

event type subscription CTL

Courage to Lead Mailing List

Accessibility Needs (Online)

CARTLarge PrintASL

Dietary Restrictions

VeganVegetarianGluten FreeShell Fish AllergyPeanut AllergyOther (check to specify)

Other Dietary Restrictions:

Accessibility Needs

ASLLarge PrintFragrance FreeFat friendly seating

Please list any accommodation requests here:

Roommate Request

What drew you to this retreat?

What are you hoping to receive from this retreat experience?

Tell us about any previous Courage and Renewal experience you have:

Emergency Contact Name (First, Last)

Emergency Contact Phone Number

Demographics

Your responses to the following questions will help CCE in our efforts to reach and provide programming relevant to diverse populations.

How do you describe your gender identity?

Are you Hispanic/Latino?

YesNo

What is your race?

If more than one, please select "Two or More"

ERAID

Total:

COVID-19 Information

https://www.lclark.edu/news/covid-19-response/

Page 2

Billing Address

First Name

Last Name

Organization Name

Address Line 1

Address Line 2

City

State/Province

Country

Zip/Postal Code

Payment Information

Name on Card

Card Number

Code

Billing Email

Authnet_Hidden_Fields