Registration Form

PARTICIPANT INFORMATION

Name  __________________________________________________________

Address  ________________________________________________________

City/State/Zip ___________________________________________________

Telephone ____________________   Email* ___________________________

* Confirmation and event details will be sent via email.

 

EVENT REGISTRATION

Please indicate the event(s) for which you are registering:

Event: ___________________________________

Date of Event: ______________       Tuition: _______

 

PAYMENT METHOD

__ Check (make payable to MAP Inc.)

__ Credit Card:   __ Visa       __ Mastercard       __ Discover

     Name (as it appears on card) _______________________________________

     Account # _________________________________    Exp Date ____ / _____

     Signature  __________________________________   Security Code _______

     Billing Address (if different from above) _______________________________

          City/State/Zip  ________________________________________________

 

 PRE-ASSESSMENT

Please take a moment to respond to the following questions. Your responses will not be shared with anyone and will ensure the event is designed to meet your needs.

1.  What specific challenges would you like to address?

 

2.  What do you hope to gain from this event?

 

 

Please print and mail your completed form with payment to MAP Inc., P.O. Box 845, Ankeny, IA 50021, email christi@meaning-and-purpose.com, or call (515) 490-0604.

 

Thank you! Your confirmation will be sent within one week of receiving your registration.