Individual Registration

Please enter information in the form below to process registration for this event:

Donald Rothberg Retreat Oct. 2024 - IMT.

First Name *

Last Name *

Phone *

Email (please make sure your email address does not contain spaces at the beginning or end) *

To help us target our advertising, please let us know how you heard about this event (TCMC website, newsletter, Facebook, Meetup, friend, etc.)?

Optional Scholarship Donation to help someone else attend (enter amount without a dollar sign)

I will attend: *

In-person

Online via Zoom

Comment/Question?

If you have a financial need, enter the amount of the scholarship help that you need (without a dollar sign), and it will be subtracted from the total fee. We will get back to you within 3-5 business days to let you know if we can meet your request. If we cannot offer the amount you requested we will issue a refund.

Scholarship Amount Needed without the dollar sign

Please list the reason you need a scholarship

How much of the retreat will you be attending *

Entire Weekend

Friday Night Only (If retreat fills, first priority will be given to those attending entire weekend)

Payment Information

Amount

Payment processing fee

Gross amount

Payment Method *

Paypal or Credit Card Mail a check to TCMC (1147 N Howard Blvd 85716) or Pay in person with check or cash

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Holder Name*