Haven_Registration_Toolkits 30/50

Welcome to on-line registration for The Haven Toolkits.

We look forward to receiving your registration request.

Thank you for your interest in our programs.

On the following pages you will be asked to:

Confirm the location and date of the Haven Toolkits you wish to attend
Provide personal information required to process your request
Authorize the registration fee via credit card. Payment is processed via a secure integration with PayPal.

You may pause at any time and return at a later date to complete this request. To pause, select "Save Answers and Resume Later" in the grey bar near the bottom of this window.

Prior to sending this on-line registration request you will have the opportunity to review the information you provided and make adjustments as needed. After you "Send" the information you will receive an email confirming receipt.

We will contact you within 24 hours following receipt of your registration request.

If you have questions about a program, the registration process or The Haven in general please contact us at register@haven.ca or 1 800 222 9211 extension 1.

OK, let's begin ...

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The Haven - Registration Request

First name of participant

Given name, as the person who will participate in the program.

Last name of participant

Surname, as the person who will participate in the program.

First Name of 2nd participant

Given name, as the additional person who will participate in the program.

Last Name of 2nd participant

Surname, as the additional person who will participate in the program.

Additional participants

Please list FIRST and LAST NAME of additional people. Multiple persons may be registered using the same form providing that the mailing address, email, phone and credit card information is the same for all persons listed.

Country

Mailing address line 1

Mailing address to be used for communications related to this registration.

Mailing address line 2

City

Address including country name

If not Canada or United States, enter complete mailing address in the box above.

Province / State

Postal code

Format B4C 2A3

State

Zip code

Format 12345 or 12345-1234

Email address

Used to acknowledge this registration request, and to provide other important information in advance of the program start date.

Alternative email address

If entered, we will also send correspondence related to this registration to this email.

Primary phone number

Home, mobile, work or other number we may call if we have questions this this registration request.

Other phone number

If applicable, secondary mobile, work or other number we may call if we have questions this this registration request.

The Haven - Credit Card Authorization

Cost for 1 day, new $

Cost for 2 days, new $

Cost for 1 day, returning $

Cost for 2 days, returning $

I authorize The Haven to charge my credit card for the following amount: (1-1-N) $

1 person, Day 1 only or Day 2 only, new participant. Charge will appear as HAVEN FOUNDATION.

I authorize The Haven to charge my credit card for the following amount: (1-2-N) $

1 person, for both Day 1 and Day 2, new participant. Charge will appear as HAVEN FOUNDATION.

I authorize The Haven to charge my credit card for the following amount: (2-1-N) $

2 people, Day 1 only or Day 2 only, new participant. Charge will appear as HAVEN FOUNDATION.

I authorize The Haven to charge my credit card for the following amount: (2-2-N) $

2 people, for both Day 1 and Day 2, new participant. Charge will appear as HAVEN FOUNDATION.

I authorize The Haven to charge my credit card for the following amount: (3-1-N) $

3 or more people, for Day 1 only or 2 only, new participants. Charge will appear as HAVEN FOUNDATION.

I authorize The Haven to charge my credit card for the following amount: (3-2-N) $

3 or more people, for Day 1 and 2, new participants. Charge will appear as HAVEN FOUNDATION.

I authorize The Haven to charge my credit card for the following amount: (1-1-R) $

1 person, Day 1 only or Day 2 only, returning participant. Charge will appear as HAVEN FOUNDATION.

I authorize The Haven to charge my credit card for the following amount: (1-2-R) $

1 person, Day 1 and 2, returning participant. Charge will appear as HAVEN FOUNDATION.

I authorize The Haven to charge my credit card for the following amount: (2-1-R) $

2 people, Day 1 only or Day 2 only, returning participant. Charge will appear as HAVEN FOUNDATION.

I authorize The Haven to charge my credit card for the following amount: (2-1-NR) $

2 people, Day 1 only or Day 2 only, 1 new and 1 returning participant. Charge will appear as HAVEN FOUNDATION.

I authorize The Haven to charge my credit card for the following amount: (2-2-R) $

2 people, Day 1 and 2, returning participant. Charge will appear as HAVEN FOUNDATION.

I authorize The Haven to charge my credit card for the following amount: (2-2-NR) $

2 people, Day 1 and 2, 1 new and 1 returning participant. Charge will appear as HAVEN FOUNDATION.

I authorize The Haven to charge my credit card for the following amount: (3-1-R) $

3 or more people, Day 1 only or Day 2 only, returning participant. Charge will appear as HAVEN FOUNDATION.

I authorize The Haven to charge my credit card for the following amount: (3-1-NR) $

3 or more people, Day 1 only or Day 2 only, 1 new plus returning participant. Charge will appear as HAVEN FOUNDATION.

I authorize The Haven to charge my credit card for the following amount: (3-2-R) $

3 or more people, Day 1 and 2, returning participant. Charge will appear as HAVEN FOUNDATION.

I authorize The Haven to charge my credit card for the following amount: (3-2-NR) $

3 or more people, Day 1 and 2, 1 new plus returning participant. Charge will appear as HAVEN FOUNDATION.

Quantity of purchase

Total charge $

Cardholder's full name as it appears on the credit card.*

FULL NAME as it appears ON CREDIT CARD

Credit card*

Payment is processed via a secure integration with PayPal.

Please review the following before submitting your registration request:

Registration ID: {$_submission_id}

Submitted: {$_submission_time}

Program: {$29659063 Please select a program}

Participant: {$29659076 First name} {$29659077 Last name}

Phone: {$29659094 Primary phone number}

Email: {$29659092 Email address}

Amount to be charged to credit card: $ {$29662591 Total charge}

If changes are needed, please select "Back" and modify your entries. You may also select "Save Answers and Resume Later".

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