Register for the 2024 Family Constellations Foundation Facilitator Training Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneOffice PhoneCell Phone*FaxEmail* Occupation Previous TrainingsGoals for this TrainingThe cost of the training is $3,000 which includes a non-refundable $250 deposit. If you pay the full amount now, you will receive a $100 discount and the total will be $2900. A payment plan is available wherein you pay the non-refundable $250 deposit now, and then five installments of $550 will be due at the beginning of each of the first five training weeks.Please choose:* I will pay the full $3000 tuition now and be eligible for a $100 discount, for a total of $2900. This includes a non-refundable $250 deposit. I would like to enroll in the payment plan and pay just the non-refundable $250 deposit now. I will pay the $550 for the weekend. I will pay the agreed upon amount per my payment plan (enter amount below). Amount to pay now: Total $0.00 Please read the text on this page, check the box at the bottom of the page indicating you have read this page and agree to its terms, then click the Next button to proceed to enter your billing information. Tuition Payment Agreement This agreement between you and The Hellinger Institute of DC, and Susan Ulfelder is to establish a payment plan for the 6 Module Training in Hellinger Family Constellations presented by Susan Ulfelder and other guest lecturers, if available. This training will be held primarily online via Zoom unless otherwise noted. The training will consist of six 3-day weekends, Friday – Sunday. Hours are 9 am-5 pm each day. The tuition is $3,000 with a non-refundable deposit of $250 required for registration. The balance of the tuition may be paid in full at the beginning of the training (which entitles you to a $100 discount) or may be paid in equal installments of $550 at the beginning of each of the first five training weekends. Payments may be made by credit card or personal check made payable to Hellinger Institute of DC. Cancellation and Refund Agreement I agree to the above tuition payment schedule. I understand that I have a one-time option to discontinue the training within 5 days after participation in the first training weekend and receive a refund for any monies paid ahead for the remaining weekends. If I find it necessary to discontinue my participation at a later time, I will not receive a refund and I agree to pay the full year’s tuition whether or not I finish the training. I understand I will be entitled to participate in future training in Hellinger Family Constellation Work for the prepaid sessions missed at no additional charge. I understand that all cancellation requests must be made in writing; phone cancellations will not be honored. Release 2024 Family Constellations Facilitator Training All trainees’ attendees are requested to read the below text in order to participate. I understand that this training may bring up issues of a highly personal nature that may cause me to experience emotional or physical responses that may be unexpected and/or unpleasant. Further, I understand that I may experience mental, emotional, physical, or spiritual distress and that such distress may also cause unpleasant symptoms. What is experienced in this training may create physical manifestations on my part or on the parts of other participants; I understand that there is a risk of accident, injury, and emotional distress. I agree to assume this risk, including but not limited to the types of responses and manifestations described. I confirm that I do not currently suffer from any mental or physical impairment, and have not been diagnosed in the past with any disorder, condition, or injury, either physical or mental, that might make it inadvisable for me to assume such risks. I agree to respect the confidentiality of any disclosure made within the course of this training and will not discuss any details of the work outside the meeting space. This training is not designed as a substitute for therapy or as a substitute for any other professional consultation. It is designed as an educational venue only. I hereby grant the Hellinger Institute of DC all rights and permission to audio and/or record my participation in the workshop. I acknowledge that the workshop may be recorded in its entirety. Further, I understand and fully accept that these recordings will be used for teaching purposes only with the trainees of the training program. By checking the box below, I acknowledge that I willingly agree to hold harmless and release from all liability the organizers, facilitators, and participants in this workshop, including Susan Ulfelder, Lynne Miller, the Hellinger Institute of DC, and the facility where the workshop is being offered. Agreement* By checking this box indicates that I have read, understood and agreed to the terms of the tuition payment agreement, this informed consent and release form, and the cancellation agreement. I willingly agree to hold harmless and release from all liability the facilitators, organizers, and participants in this training. Total $0.00 Payment Method Credit Card PayPal Billing Address* Same as previous Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Billing Phone*Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name Payment MethodPayPal Checkout MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name