Please use the 3-step process below to register for

Chapel Hill, NC  ~  November 14, 2008 
 

Complete the form below [Step 1] and

After verifying your information [Step 2]

Select (and complete) a Payment Method [Step 3].
 

Step 1

(Note that fields with *'s REQUIRE INPUT.)

HIDDEN FIELD: Enter program Name

*First Name(s)

  

Middle Name
or Initial

  

*Last Name.

  

Suffix

      Jr., Ph.D., RN, MD, etc.

*Nickname.

   The first name you use for nametags

*Gender

Male  Female

*Email

  

*Birthdate.

   Month       Year

Organization

*Address Line 1

  

Address Line 2

  

*City.

    *State  . *Zip.

Country.

*Primary or
Home Phone

Business

Cell

Website

 

Cost and Refund Information

The cost of this workshop is $95; registrations received before October 18 will receive a $20 discount. The fee includes lunch.
 

Check one:    Early Registration  ~  $75        Regular Registration  ~  $95

Refunds — Full refunds, less a registration processing fee of $10 will be given for cancellations received on or before October 17, 2008. Thereafter, an additional portion of the deposit may be retained to cover incurred costs. Full refunds will also be given in the event an applicant cannot be accommodated or the program is cancelled.

Contributions and Financial Assistance — We hope no one will be prevented by financial need alone from attending this program. Consequently, we strive to secure external support or contributions from other participants to underwrite a pool of "scholarship funds."  We also invite attendees able to do so to consider becoming a co-sponsor of this program.
 
It would be difficult for me to attend without financial assistance.    Yes  No
 
 I wish to contribute to a "scholarship fund."
         Yes    No 		Enter amount of your contribution
                      

Please tell us how you heard of Second Journey.

 

Please tell us something about yourself. This should include the work in your life which you have found meaningful and rewarding and the significant experiences that have molded you. But beyond these, please also address the following questions:

  • What are you passionate about with respect to creating community in later life?

  • What big questions do you bring to this gathering?

  • What outcomes do you hope for?

After completing the form, please press SUBMIT below to review your information.

  

 

Second Journey, Inc.
4 Wellesley Place, Chapel Hill, NC 27517
(919) 403-0432

  

Second Journey, Inc. is a 501(c)(3) tax-exempt nonprofit corporation