Emotion-Focused Ketamine-Assisted Psychotherapy
Workshop: Emotion-Focused Ketamine-Assisted Psychotherapy

Dates: Monday, November 9, 2020
Time: 9 am - 4:30 pm ET (Convert to your Time Zone at: https://www.timeanddate.com/worldclock/converter.html)

Location: Online Live Stream Event
Early-Bird Cost: $199 CAD + 13% HST (=$224.87) by October 8, 2020
Regular Cost: $225 CAD + 13% HST (=$254.25) after October 8, 2020
Registration Deadline: November 5 at 12 pm ET

*Group Rates available for groups of 5+ people registering together OR for individuals registering for more than one workshop. See www.missionempowerment.ca/discounts for more information*

Important Notes:
1) 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.

2) Please note that the attendee names entered on this form will be used for the sign in sheet and certificates of completion, exactly as entered. Please be sure to capitalize the first letter in the first name and last name, otherwise there will no be capitals on the certificate.

**Note: This form is only for people who will be paying by E-TRANSFER (CAD bank accounts only). For those wishing to pay by credit card or Paypal, please go to the workshop page at www.missionempowerment.ca and choose the correct option under the Registration heading.
First Name: *
Last Name: *
Email Address: *
Street Address: *
City: *
Province/Territory/State: *
Country: *
Postal Code: *
Job Title: *
Company/Organization: *
(if you are not employed by an organization, please just write your full name in this section - "self-employed" if applicable)
Mobile/Home Phone (Please enter the best number to reach you on the day of the workshop in the unlikely case of cancellation or emergency): *
Please enter just ONE phone number where you would be most likely to be reached on the morning of the event.
How did you hear about this event? *
Check all that apply
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 session only; it will not include breakout rooms. Recording is set to “speaker view” so only those speaking on camera will be recorded. If you choose to participate on camera and speak to the large group, you agree to be recorded. Workshop access is restricted to one person per purchase.
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.
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