Register for a Course or Workshop

Please fill out the following form to confirm your spot.

Contact Information
Name*
First Last
Email*
Phone
Course/Workshop Selection
Which course/workshop(s) are you registering for?*
- Mindful Concussion course starting October 1, 2022
- COAT Webinar (see link on Offerings page on my website)
- Free bi-monthly Circle-Ups for Survivors
Payment
To reserve your spot, please pay imediately after submitting this registration form.

You may cancel for a 100% return on payment up to one week in advance. Consult the sliding scale for the courses/workshops you are attending and send your payment.
My payment method will be:*
- E-transfer to jessierainannesmith@gmail.com
- Paypal (a link to pay will be provided once you submit this form)
Questions?
Let me know your questions or thoughts below:*
Email
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Register for a Course or Workshop

Please fill out the following form to confirm your spot.

Contact Information

Course/Workshop Selection

Payment

Questions?

Get instant access to a free Cultivating Calm with Concussion video!

Success! Thank you for joining my community.