Well Being Foundations of Personal Transformation – 2018 Program Registration Well-Being Foundations of Personal Transformation Module 1 – March 2-4, 2018 Module 2 – April 6-8, 2018 Module 3 – May 4-6, 2018 Module 4 – June 1-3, 2018 ( 9:30 to 5:30 each day) Fairfax, VA Registration - Well-Being Foundations 2018 Contact Information Full Name * Email Address * Phone Number * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Waiver Please review and sign the following waiver: Any and all aspects of the course are undertaken voluntarily on your part. The course is not meant as therapy or as a replacement for any other professional service that you would engage for your physical or mental health. The waiver is your acknowledgement that the Personal Transformation and Courage Institute is released from any liability related to your participation in the course. The undersigned knowingly releases and holds harmless the Personal Transformation and Courage Institute and its agents from any and all claims, suits, proceedings, costs, losses, expenses, damages, and liabilities, including but not limited to attorney’s fees and court costs, caused by and arising out of, or in connection with his/her participating in this course. E-Signature * Payment Tuition for this course is $2,950. Refund Policy: Cancellations that are made one week prior to the starting date of the course are eligible for a refund. After that date, a refund is available if we are able to fill your spot with another course participant. A waiting list will be maintained for those who are interested if no registration spots are available. Refunds will be issued in the same form as original payment. Promo Total: $2,950 Payment Plan Please check this box if you will be making multiple payments for this course. Payment Type Please indicate how you will be paying for this course: PayPal / Credit Card Check Initial Payment To pay via PayPal account or credit card select this option and then click the "REGISTER" button below and complete the payment process on PayPal's secure website. Select the "Pay with Debit or Credit Card" option on the first page to use your card and proceed without creating a PayPal account. Please make your check payable to the Personal Transformation and Courage Institute. Please use check's memo line to indicate which course you are paying for. Mail check to: PTCI P.O.Box 914 Virginia Beach, VA 23451 If you are human, leave this field blank.