Registration Brainspotting to Heal Perinatal Trauma Training Registration Form Brainspotting to Heal Perinatal Trauma Training Registration Form First and Last Name * Email * Please use same email address you will use to register for the Zoom meeting Phone * Best contact phone number before and during training Are you Registering for Day 1 or Both Days of Training? * Registering for Day 1 ONLY October 24, 2022 9:00am to 5:00pm Eastern Time USA (I am not yet Phase 1 Brainspotting trained or only plan to attend this day)|$280.00 Day 1 ONLY plus Continuing Education (CEs)|$305.00 I AM BRAINSPOTTING PHASE 1 Trained: Registering for Day 1 and Day 2, Monday October 24 and Tuesday October 25, 2022 9:00am to 5:00pm Eastern Time USA |$560.00 Registering for Day 1 and Day 2, plus Continuing Education (CE's)|$585.00 If Registering for Both Days, Who was your Phase 1 Trainer, was it live or online and what month and year did you take the training? If you have completed Phase 2, share your trainer and month and year taken. * Profession and Professional Licensing Information * Full Physical Address you will be located during the training * Full Physical Address you will be located during the training Full Physical Address you will be located during the training Full Physical Address you will be located during the training City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Emergency Contact Name and Relationship to You * Emergency Contact Phone Number * Please include country code. What topics would you like covered in the training or what question do you hope is answered? * I agree to have Supportive Solutions LLC use my email contact to advise me of any further training and electronic communications they are offering. * Yes No I have read and accept Supportive Solutions, LLC Training: Policies and Guidelines of participation in this training of Brainspotting to Heal Perinatal Trauma * Yes No On clicking "Submit," you will be redirected to Paypal, where you can pay with a Paypal account or as a Guest by using Debit/Credit Card by selecting the "Pay with Debit or Credit Card" button on the bottom of the screen. If you are human, leave this field blank. Submit