Registration Form & Payment

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

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How Will You Attend This Training?

In-Person (at Wellspring of Life Counseling & Play Therapy Center, PLLC, inside the Albert G. Combs Conference Room)

Live Webinar (by selecting this option, you agree to the Live Webinar Participant Guidelines that can be found under each workshop at www.wellspringoflifesa.net/training)

Photo/Video Release *

I DO grant permission to WOL Counseling & Play Therapy Center, PLLC, to use images that include myself, the named registrant. Such use includes the display, distribution, publication, transmissions, or otherwise use of photographs, images, and/or videos taken for use in materials that include, but may not be limited to, printed materials, such as Brochures, Newsletters, Videos, and digital images used on WOL's website, social media pages (i.e., Facebook, Instagram, etc.), and any other form of electronic and non-electronic communication for the purpose of promotion and advertisement.

I DO NOT grant permission to WOL Counseling & Play Therapy Center, PLLC, to use images that include myself, the named registrant. Such use includes the display, distribution, publication, transmissions, or otherwise use of photographs, images, and/or videos taken for use in materials that include, but may not be limited to, printed materials, such as Brochures, Newsletters, Videos, and digital images used on WOL's website, social media pages (i.e., Facebook, Instagram, etc.), and any other form of electronic and non-electronic communication for the purpose of promotion and advertisement.