Register for Conscious Parenting
4 Week Series
Tuesdays - 5:00pm-7:00pm
February 2023
Parent/Guardian Information
Parent/Guardian First Name
Parent/Guardian Last Name
Street address
City
Postal Code
Province
Please select...
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Parent/Guardian Email
Parent/Guardian Phone
Child care
Do you need child care for any of the sessions?
Please select...
Yes
No
For how many children?
Please select...
1
2
3
4
Check off the sessions you need child care for
February 14, 2023
February 21, 2023
February 28, 2023
March 7, 2023
# of session(s) selected for child care
Total Amount Due
($CAD):
Child 1 Information
Child 1 First Name
Child 1 Last Name
Child 1 Date of Birth
Does your child have any allergies?
Please select...
No
Yes
If yes, please provide additional details:
Child 2 Information
Child 2 First Name
Child 2 Last Name
Child 2 Date of Birth
Does your child have any allergies?
Please select...
No
Yes
If yes, please provide additional details:
Child 3 Information
Child 3 First Name
Child 3 Last Name
Child 3 Date of Birth
Does your child have any allergies?
Please select...
No
Yes
If yes, please provide additional details:
Child 4 Information
Child 4 First Name
Child 4 Last Name
Child 4 Date of Birth
Does your child have any allergies?
Please select...
No
Yes
If yes, please provide additional details:
I have read and agree to the refund policy
View the refund policy
Payment
Payment Information
Total Amount Due
($CAD):
Name on Card
Card Number
MM
YY
Code
Billing Email
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Contact Information