Recovery Week Registration

Confirm your seat in our Recovery Week

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Comments

TAC Enrollment Form 2021-2022

9/30/2021 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 Flag

YesNo

FERPA Document Flag

YesNo

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

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 Agreement

The 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 Month

Expiration Year

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:

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Contact Information