SSCWPC 2023 Registration Form SSC Weekly Practice Cycle 2023 Please Note:If you choose the PayPal option and 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* My pronoun is (e.g. she/her, they/them, he/him): A little more about you:Address*Your full postal address is not required until you are in the PayPal subscription payment section. City State / Province / Region AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country To help us work with you:Please free free to contact Kristy Arbon (kristy@heartworks.training), if you have personal concerns that you would rather discuss in person. Your information will be kept confidential.What do you hope to get out of this program?What current stressors are your dealing with that you'd like to share about?Are there any physical or mental health concerns/conditions that might affect your participation in this program?Have you experienced things you would consider traumatic in your life? If so, are they still affecting you? How are they affecting you (e.g. flashbacks, nightmares, intrusive thoughts, difficulty concentrating)?Are you seeing a therapist/counsellor?Is there anything else you'd like us to know so that we can support you?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:Your first subscription payment will pay for your first month of the program. Subsequent subscription payments will occur around the same time each month. You can cancel your subscription at any time.Price*Please choose your subscription level below. I'll invest $10/month I'll invest $15/month I'll invest $20/month I'll invest $25/month I'll invest $30/month I'll invest $35/month I'll invest $40/month I'll invest $45/month I'll invest $50/month 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 EmailThis field is for validation purposes and should be left unchanged. Δ
