Course Scholarship Payment

Course(Required)

Name(Required)

First Last

Pronouns

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Profession(Required)

Summary of work with Eating Disorders treatment and recovery(Required)

Summary of experience with somatic therapies(Required)

Additional notes or message

Refund Policy(Required)

I have read and agree to the Refund Policy (View).

COVID-19 Policy(Required)

I have read and agree to the COVID-19 Policy (View).

Scholarship Price You Were Given(Required)

Credit Card(Required)

Card Details

Cardholder Name

Course Scholarship Payment – Tier 1