In-Person Course Registration Form

Training Date(Required)

January 27th – 31st, 2025 – Dinuba, California – 5 Day Training

Attendee Name(Required)

First Last

Attendee Agency/Organization(Required)

Attendee Title

Attendee Email(Required)

Attendee Phone Number(Required)

Are you currently an active member of a peer support team?(Required)

Note – this is not required to take the course but the information helps us better tailor our course.

Yes

Billing Information

We will send an invoice to this email address

Street Address Address Line 2 City State ZIP Code

Phone Number

Email Address(Required)

Acknowledgment of cancellation policy:(Required)

By checking “Yes,” you acknowledge that you are officially enrolled in the course and agree to the following cancellation terms:

Cancellations 30 Days or More Prior to the Start of the Course: A full refund will be provided, minus a $50 cancellation fee.
Cancellations Less Than 30 Days Prior to the Start of the Course: No refunds will be issued. We can swap the attendee if you are able to send someone else in your stead.

Yes

We appreciate your understanding and look forward to seeing you.