SSCON 2019.11 Registration Form Somatic Self-Compassion Online (SSCON) | November 22, 2019-February 21, 2020 Please Note:If you choose the PayPal option and you are not taken to the PayPal page after completing this form, it's likely that you have missed completing one of the required fields. Please scroll down and check to see if there is an error message if you are not taken to PayPal.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:Occupation:A little more about you:Address City State / Province / Region AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country To 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:Price*This is a gift economy/dana offering. Please take some time to reflect on what this course feels worth to you, choose your level of payment and enter it in the box below. Zero is fine. The amount entered will be in US dollars. US$1 is approximately the same as $1.45 Australian, $1.60 New Zealand, €0.91, $4.10 Brazilian Real, $1.30 Canadian, £0.80 Payment Type* PayPal/Credit Card Check None 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 NameThis field is for validation purposes and should be left unchanged.