Basic Registration Form

Basic Registration

Personal Details

First Name
Last Name
Please use date format MM/DD/YYYY. For example, January 16 2000 would be "01/16/2000".
Email
Be as detailed as you can.

Business Details:

Family Details:

Who shared the Course with you? (Sponsor)

Emergency Contacts

Repeating Students Only:

For Minor's Guardian Only

Tuition

All prices listed are in USD.

Payment Information

By filling in my name and date below, I acknowledge that I have read, understand and agree to all of the above terms and conditions.

I acknowledge that I have read, understand and agree to all of the above terms and conditions of the Refund Policy.

Medical and Psychological Information

Due to the participatory nature of the course, the following information is required to attend. This is done in order to provide the best learning environment possible for you and the other participants. Please answer the following questions by checking the appropriate response. Your answers are kept confidential except for possible disclosure to your physician, psychiatrist, psychologist or therapist, if applicable. If you have any questions or concerns regarding the following, please contact the Pathways office.
The Basic Course is based on an educational model, not a medical model. None of the Pathways staff are licensed psychiatrists or psychologists.