Victim Assistance Program · The Essentials Registration & Payment Form

The Essentials Registration

How did you hear about us?

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Who specifically told you about The Essentials?

Which course are you registering for?

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How will participants be joining us?

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All of our classes are in person. However, if three or more individuals desire to join virtually, we'd be happy to offer a hybrid course! If you select the live virtual option below, and the class does not meet the minimum virtual participants, we will gladly provide you with a refund, or register you for a different class. PLEASE NOTE: At this time, our May class will ONLY be offered In-Person.

Please let us know if any accomodations are required.

Purchaser Contact Information

If you are registering and paying for yourself (or others), please provide your information below.

Organization/Employer

Purchaser's Name

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First Name

Last Name

Email

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Verify Email

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Mailing Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Phone

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Course Fees

If you have a discount code, please enter it below.

Essentials Full Price	Quantity
$495 - Registration Fee

Essentials Half Price	Quantity
$247.50 - Half Price Registration Fee

Course Participants

Please include the names of those who are registering for the course. In addition, valid email addresses are required for individual participants as each will be required to log into a Learning Management System to complete required course work.

How many people are you registering for?

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1) Participant

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First Name

Last Name

1) Email

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Verify Email

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1) Ohio CE License # if applicable

2) Participant

First Name

Last Name

2) Email

*

Verify Email

*

2) Ohio CE License # if applicable

3) Participant

First Name

Last Name

3) Email

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Verify Email

*

3) Ohio CE License # if applicable

4) Participant

First Name

Last Name

4) Email

*

Verify Email

*

4) Ohio CE License # if applicable

5) Participant

First Name

Last Name

5) Email

*

Verify Email

*

5) Ohio CE License # if applicable

6) Participant

First Name

Last Name

6) Email

*

Verify Email

*

6) Ohio CE License # if applicable

7) Participant

First Name

Last Name

7) Email

*

Verify Email

*

7) Ohio CE License # if applicable

8) Participant

First Name

Last Name

8) Email

*

Verify Email

*

8) Ohio CE License # if applicable

9) Participant

First Name

Last Name

9) Email

*

Verify Email

*

9) Ohio CE License # if applicable

10) Participant

First Name

Last Name

10) Email

*

Verify Email

*

10) Ohio CE License # if applicable

Almost done!

After you enter your payment information....

You will receive an email confirmation of your purchase.
Our education department will create individual accounts in our Learning Management System (LMS) using the participant's name and email address(s) provided.
- Each class participant will receive an email with login instructions one week prior to the start of the class.
- All class participants, both in person, and virtual, will be required to use the LMS to complete course activities or assignments.
If you have any questions, or need to make changes to your registration, please contact Dana at DZedak@victimassistanceprogram.org