Recovery Week Registration Confirm your seat in our Recovery Week Please review the error(s) below.Lookup returned no record and aborted connector execution. For full functionality of this page it is necessary to enable JavaScript. Comments TAC Enrollment Form 2021-20229/30/2021 GL Cloned from TAC Enrollment 2020-2021 form. Made changes to accomodate Transact payments, particularly in the Opportunity Name and Payment Type SalesForce pre-populated parameters (Do Not Change!) ContactID ApplicationID Campaign ID Event date (Opp. Close date): Deposit Amount Application Amount Deposit Paid Date Total Certificate Cost Payment for: Program Program Track Payment Description Addition Last Name First Name Fund ID Facilitator Feedback Document FlagYesNo FERPA Document FlagYesNo SalesForce Record Types - Should not need to be updated Hidden Calculations Installment Amount First Name Last Name Please describe your dietary restrictions Emergency Contact Please consider choosing someone who could offer safe emotional support should the need arise. First Name Last Name Phone Number Email Relationship Dual Relationships Please reference your acceptance email and follow the link to our facilitator list. Please provide the name(s) of anyone with whom you have connections and the nature of your relationship. Additionally, please let us know if you have a relationship with any others who you know are participating: Enrollment Deposit Payment Schedule AgreementThe cost of the program may be paid in full or in two or four installments. Payment due dates are available on the offering-specific detail page on our website and in the Covenant & Release of Claims provided in your acceptance email. Payment: I would like to pay my deposit and fee in full todayI would like to pay my deposit today and my balance in installments Credit Card Information First Name Last Name Credit Card # Security Code Expiration MonthPlease select... 01 02 03 04 05 06 07 08 09 10 11 12 Expiration YearPlease select... 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 My signature below certifies that I have read and understand the information provided in the Covenant and Release of Claims. I understand that I am submitting a non-refundable, non-transferrable enrollment deposit that secures my seat and creates a financial commitment. By submitting this Notice of Intent I am willfully choosing to enroll in this offering. Please type your full legal name, understanding that it is legally equivalent to your signature: Authorize.net parameters (Do Not Change) Authnet_Hidden_Fields Contact Information