Circle of Security

Circle of Security Online Zoom Group - September 2022 - Request to Register

Please be aware that completing this form does not ensure you are registered yet. You will not be registered (or charged) in the event that the class or workshop is full, or if your form is received after the registration cut-off date. Either way we'll be in touch once we hear from you!

Your Name*
First Last
Your Email*
Your Phone Number*
The age of your child (or children):*
Payment
Online registration for classes and workshops must be paid for by credit card. Please refer to the corresponding workshop or class webpage to find the cost. If you would like to pay using an alternate payment method, please contact our reception at 604-284-7827 ext. 0.
Cardholder Name*
First Last
Account Type*
Account Number*
3 Digit Security Code*
You can typically find this number on the back of your credit card.
Expiration Month*
Expiration Year*
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Consent*
I understand that classes are offered as a whole, and refunds will not be available for missed sessions.
Consent*
I authorize the above named business to charge the credit card indicated in this authorization form, according to the terms outlined above, and according to the Alongside You cancellation policy. I authorize Alongside You to charge my account for services rendered, including retainer payments. This is permission for recurring transactions related to clinical services, and does not provide authorization for any additional unrelated charges or credits to the account. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
Cardholder Signature*
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Circle of Security

Circle of Security Online Zoom Group - September 2022 - Request to Register

Payment