SSCON 2018.5 Registration Form Somatic Self-Compassion Online (SSCON) | May 28-September 3, 2018 About you:General Data Protection Regulation (GDPR) Agreement* I consent to having this website store my submitted information so they can respond to my inquiry Name* First Last Email address* I identify my gender as:Profession:A little more about you:Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Daytime phone*Evening phone*Cell phoneTo help us work with you:Please free free to contact Kristy Arbon (email@example.com), if you have personal concerns that you would rather discuss in person. Your information will be kept confidential.Are there any physical or mental health concerns/conditions that we should know about or you would like to tell us about?Have you experienced things you would consider traumatic in your life?Are you seeing a therapist/counsellor?Have you done any meditation before? If so what kind, and was it helpful?How did you hear about this course?*Please choose all that apply. Social Media Word of Mouth HeartWorks website Email notification from Kristy Course selection and registration:Early-Bird Registration (before April 8, 2018 - fee increases by $50 from this date)*Please choose your level of registration below. Please contact Kristy (firstname.lastname@example.org) if you need to discuss a different payment arrangement. I don't want finances to get in the way of you accessing this course. I will consider any offer to include you in this program.I can help with scholarships ($400)I'm happy to be here at the regular rate ($300)I just need a little help to join the group ($200)Coupon Payment Type* PayPal/Credit Card If you are paying by check, please make the check out to: Kristy Arbon HeartWorks Training PO Box 510441 St Louis, MO 63151Total $0.00 Payment confirmation You will be placed on a waiting list until your payment is received and confirmed. You are advised to send in your payment as soon as you register, to avoid disappointment. Cancellation Cancellations up to 3 weeks before the course will be refunded in full. Cancellations between 3 and 1 week before the course are subject to a 50% fee. No refund is provided after that point, except on compassionate grounds (evidence may be required)PhoneThis field is for validation purposes and should be left unchanged.