Registration for Mid-Atlantic Region Integrative Facilitation Training

Please fill out the form and then drop a check in the mail.

Mail check to:
Karen Stupski
21300 Heathcote Rd.
Freeland, MD 21053

Do you have any questions?

CONTACT PERSON
Karen Stupski
Phone: 410-357-9523
Email: karen@heathcote.org (subject line “Integrative Facilitation”)

Name: *

Community or Organization:

Complete Mailing Address: *

Phone (home): *

Phone (work):

Phone (cell):

Email Address: *

Dates Attending

May 27-30, 2010:

Plan to Attend

Can Host

Sep 23-26, 2010:

Plan to Attend

Can Host

Dec 9-12, 2010:

Plan to Attend

Can Host

Mar 10-13, 2011:

Plan to Attend

Can Host

May 26-29, 2011:

Plan to Attend

Can Host

Sep 8-11, 2011:

Plan to Attend

Can Host

Jan 12-15, 2012:

Plan to Attend

Can Host

Mar 8-11, 2012:

Plan to Attend

Can Host

Payment Information

Check it out:

$325 (first week)

Full Participant:

In full ($2400)

Two payments ($1300 each)

Per weekend ($350)

Auditor:

$250 per weekend (first four)

$275 per weekend (after first four)

Total Payment: *

Make check payable to Laird Schaub. Payments are due 2 weeks prior to each class. Send to address at beginning of registration form.

Other:

Logistics Information

Food Needs:

Omnivore

Ovo-lacto vegetarian

Vegan

Other (please describe in special needs section)

Lodging Needs:

Camping

Floor

Couch

Bunk Room

Single bed in shared room

Double bed in shared room

Single bed in private room

Which type of accommodations are OK for you? Check all that apply (lodging options at the host communities may be limited so it is important for us to know all the types of accommodations that you are comfortable with).

Travel Needs:

I can provide my own transportation.

I can offer a ride to other people.

I need a ride.

Check all that apply.

Emergency Contact

Name:

Relationship:

Phone:

Email:

Allergies and Medical Conditions:

Please describe any that we should be aware of.

Special Needs:

Please describe.

Information Needed:

Send information about hosting a weekend of the Facilitation Training

Send info about the Masters degree program in Integrative Facilitation with Gaia U.

How did you hear about the workshop?:

Heathcote

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HEATHCOTE COMMUNITY 21300 Heathcote Road Freeland, MD 21053 USA (410) 343-DIRT info@heathcote.org
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Registration for Mid-Atlantic Region Integrative Facilitation Training

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